presentation anxiety nerves

Beating Presentation Anxiety: 5 Steps to Speak Confidently

• The Speaker Lab
• April 16, 2024

Table of Contents

Feeling jittery about your next presentation? If so, you’re not alone. Presentation anxiety hits many of us, but it doesn’t have to hold you back. In this article, we’ll dive into what sparks this fear and how it shows up. We’ve got you covered with strategies to prep before your talk, keep cool during the show, and even use tech tools to smooth out those nerves.

If you find that the jitters are negatively impacting your presentations, we have the strategies you need to build confidence. And if you need more help, we’ll point you towards top-notch resources for beating presentation anxiety.

Understanding Presentation Anxiety

Presentation anxiety grips many of us before we step onto the stage. It’s that stomach-churning, sweat-inducing fear of public speaking that can turn even the most prepared speaker into a bundle of nerves. But why does this happen? Let’s break it down.

Common Triggers of Presentation Anxiety

First off, it’s important to know you’re not alone in feeling nervous about presenting. This type of anxiety is incredibly common and stems from various triggers. One major cause is the fear of judgment or negative evaluation by others. No one wants to look foolish or incompetent, especially in front of peers or superiors.

Another trigger is lack of experience. If you haven’t had much practice speaking in public, every presentation might feel like stepping into unknown territory. Then there’s perfectionism; setting impossibly high standards for your performance can make any slight mistake feel disastrous.

How Presentation Anxiety Manifests

The symptoms of presentation anxiety are as varied as they are unpleasant: dry mouth, shaky hands, racing heart—the list goes on. Oftentimes, these physical signs go hand-in-hand with mental ones like blanking out or losing your train of thought mid-sentence. In addition to affecting how you feel physically, anxiety also messes with your confidence levels and self-esteem.

By understanding presentation anxiety better, we realize its grip on us isn’t due to our inability but rather a natural response that can be managed with the right techniques and mindset adjustments.

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Strategies for Managing Presentation Anxiety Before the Event

Feeling jittery before taking the stage is a common plight, but let’s not let those nerves derail our success. Here are some tried and true strategies to help keep your cool.

Planning Like a Pro

Kicking off with solid planning can be your first line of defense against presentation anxiety. Initiate by segmenting your presentation into digestible sections. This could mean outlining main points or scripting it out entirely, depending on what makes you feel most prepared. A good resource that dives deep into effective planning is Toastmasters International , where you’ll find tips on structuring speeches that resonate.

An equally crucial part of planning involves researching your audience. Understanding who will be in front of you helps tailor your message and anticipate questions they might have, making you feel more confident and connected.

The Power of Practice

You’ve heard it before, but practice really does make perfect—or at least significantly less nervous. Running through your presentation multiple times lets you iron out any kinks and get comfortable with the flow of information. For an extra boost, simulate the actual event as closely as possible by practicing in similar attire or using the same technology you’ll have available during the real deal.

If solo rehearsals aren’t cutting it, try roping in a friend or family member to act as an audience. Not only can they offer valuable feedback, they can also help acclimate you to speaking in front of others—a critical step toward easing anxiety.

Breathing Techniques That Work Wonders

Last but definitely not least: don’t underestimate breathing techniques. They have the power to calm nerves fast when practiced regularly leading up to the big day. Headspace offers guided exercises that focus on controlled breathing methods designed specifically for stress management. These practices encourage mindfulness, which can center thoughts away from anxious feelings towards present tasks—like delivering an outstanding presentation. Incorporating these exercises daily can build resilience against last-minute jitters too.

Techniques During the Presentation

Say you’ve practiced your speech a dozen times but you’re still worried about the big day. What should you do then to beat presentation anxiety? Let’s take a look.

Engage with Your Audience

Talking to a room full of people can feel daunting, especially when you don’t know any of them. But remember, your audience is there because they’re interested in what you have to say. Make eye contact, smile, and ask rhetorical questions to keep them hooked. As you speak, don’t forget about the importance of body language since it communicates just as much as your words.

If you think engagement ends at asking questions, think again. Sharing personal stories or relevant anecdotes helps build a connection. It makes your presentation not just informative but also relatable and memorable.

Maintain Composure Under Pressure

If you’re palms are sweating and your heart is racing, know that it’s okay. Feeling your pulse quicken shows you’re invested in nailing that speech, yet it’s crucial not to let these sensations throw you off track. Practice deep breathing exercises before stepping onto the stage to calm those nerves.

Besides deep breathing, adopting power poses backstage can significantly boost your confidence levels. Although it may sound crazy, this is a tip from social psychologists that has helped many speakers take control of their anxiety. Just check out Amy Cuddy’s TED talk on body language to see for yourself.

Facing unexpected tech glitches or interruptions during your speech is par for the course. Stay calm and use humor if appropriate—it shows professionalism and adaptability.

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The Role of Technology in Managing Presentation Anxiety

When giving a presentation, it’s not uncommon for your slides or videos to suddenly turn on you, malfunctioning in some way. However, while technical issues are something to prepare for, they shouldn’t keep you from considering technology an ally against presentation anxiety. Let’s look at some ways that technology can help soothe your public speaking jitters.

Presentation Software Features

Gone are the days when speakers had to rely solely on their memory or paper notes. Modern presentation software not only allows you to create visually appealing slides but also comes with features designed specifically for speaker support. Tools like PowerPoint’s Presenter View or Keynote, give you a behind-the-scenes look at your notes and upcoming slides without showing them to the audience. This lets you stay on track discreetly.

Another gem is interactive polling through platforms such as Mentimeter or Poll Everywhere . Engaging your audience with real-time polls not only keeps them involved but also gives you brief moments to collect your thoughts and breathe.

Stress Management Apps

When it comes to taming those pre-presentation butterflies in your stomach, there’s an app for that too. Meditation apps like Headspace offer quick guided sessions that can be squeezed into any busy schedule. Taking even just five minutes before stepping onstage can significantly calm nerves and improve focus.

Breathing exercises have proven effective in managing stress levels quickly. The beauty of apps like Breathe2Relax , is that they provide structured breathing techniques aimed at reducing anxiety on-the-go. As a result, it’s perfect for those last-minute jitters backstage or right before a webinar starts.

Resources for Further Support

If you’re on a quest to conquer presentation anxiety, you’re not alone. It’s like preparing for a big game; sometimes, you need more than just pep talks. Thankfully, there are plenty of available aids out there to help support you on your journey.

Books That Speak Volumes

Finding the right book can be a lifesaver. “Confessions of a Public Speaker” by Scott Berkun gives an insider look at the highs and lows of public speaking with humor and wisdom. Another gem is “TED Talks: The Official TED Guide to Public Speaking” by Chris Anderson, which pulls back the curtain on what makes talks memorable.

Beyond books, consider immersing yourself in stories of others who’ve walked this path before. A great way to do this is through podcasts or audiobooks focusing on overcoming fears and embracing confidence.

Professional Services: When You Need A Team

Sometimes self-help isn’t enough; maybe what you really need is someone in your corner guiding each step. That’s where expert coaches come in. These mentors can craft plans tailored uniquely to your situation, ensuring you’re equipped for every challenge.

Here at The Speaker Lab you’ll find plenty of resources and help if you’re looking to master the art of public speaking while tackling anxieties head-on.

Together, all these resources have one thing in common: they empower speakers at any stage of their journey towards becoming confident communicators ready to tackle any audience.

FAQs on Overcoming Presentation Anxiety

How do i overcome anxiety when presenting.

Practice your talk, know your stuff, and take deep breaths. Confidence grows with preparation and experience.

Why am I anxious about public speaking?

Fear of judgment or messing up in front of others triggers this anxiety. It’s our brain on high alert.

What is anxiety presentation?

Presentation anxiety is that jittery feeling before speaking publicly. It stems from fear of failure or negative evaluation.

What can I take for presentation anxiety?

Talk to a doctor first but beta-blockers or natural remedies like chamomile tea might help ease the jitters safely.

Feeling nervous before a presentation is common. However overwhelming it might feel, know that mastering this fear is possible. Remember: practice makes perfect. By prepping ahead of time and getting familiar with your content, you can dial down the nerves.

As you’re in the spotlight, make sure to maintain a lively interaction with those watching. This builds confidence on the spot. Tech tools are there for help too. They can streamline your preparation and delivery process significantly.

Don’t be shy about asking for more info if you’re looking for something specific. We’re here to help and make sure you find exactly what you need. So what are you waiting for? It’s time to get out there and nail that presentation!

• Last Updated: April 11, 2024

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More From Forbes

How to overcome presentation anxiety, according to an award-winning cognitive scientist.

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NEW YORK, NY - FEBRUARY 23: Sian Beilock, Bernard College President, attends the 2018 Athena Film ... [+] Festival Awards Ceremony at The Diana Center At Barnard College on February 23, 2018 in New York City. (Photo by Kris Connor/Getty Images for Athena Film Festival)

Sian Leah Beilock is a cognitive scientist and expert in achieving peak performance under pressure. In her bestselling book, Choke , Beilock reveals confidence-building strategies for anxiety-inducing events like Olympic competitions, test-taking and public-speaking opportunities.

Beilock faced her own pressure-filled moment in 2017 when the TED conference invited her to present her research to a live audience. Beilock, now president of Barnard College in New York City, talked to me recently about applying her research to prepare for the TED stage.

Beilock realized that the TED audience would have high expectations from an expert who teaches people how to avoid choking under pressure. And that’s on top of the stress that already comes with giving a TED talk.

“I do a lot of public speaking, but the TED talk was particularly nerve-wracking because it has an aura around it,” Beilock said. “And my mom came to watch— which is just another added level of pressure!”

Beilock applied an effective strategy to alleviate anxiety in high-stress situations. She calls it pressure training—practicing under pressure.

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Pressure training simply means practicing your sport or speech in an environment that elevates stress hormones. It’s a strategy that works for Olympic athletes as well as business professionals preparing for an important pitch or presentation.

Sian Beilock's book, Choke

“Even practicing under mild levels of stress can prevent you from choking when high levels of stress come around,” Beilock says.

Let’s say you’re experiencing some anxiety over an upcoming Zoom presentation your boss asked you to deliver to the team. A simple example of practicing under ‘mild stress’ would be to schedule a meeting where you’re the only one invited. Bring up the presentation, share your screen, and press ‘record’ as you deliver it from start to finish. Identify those areas where you can improve next time—and there will be another practice. And another. And another.

For the next practice session, turn up the stress just a little by inviting a friend or peer to the ‘rehearsal.’ The point of the exercise is to mimic the environment you’ll find yourself in when it’s time for the actual presentation. If the presentation takes place in-person, then stand up, take a clicker in your hand, display the presentation on a screen behind you, and deliver it out loud. If you can invite someone to sit and watch in person, that’s even better.

“Simulating low levels of stress helps prevent cracking under increased pressure, because people who practice this way learn to stay calm, cool, and collected in the face of whatever comes their way,” says Beilock.

Rehearse in Real-World Conditions

According to Beilock, our brains react most negatively before a stressful event and not when it’s actually happening. Have you ever had so much anxiety about an upcoming presentation that you couldn’t sleep for days—or weeks—only to discover that it wasn’t as bad as you had imagined? Maybe your presentation was a hit, and you wasted hours worrying about it. That’s your brain stressing you about before the event.

Beilock says the strategy works effectively because it “bridges the gap between training and competition.” By training for the event over and over in ‘real-world’ conditions, your brain learns to see the speech not as a threat but as an event that you can handle successfully.

According to a recent McKinsey study , communication skills like public speaking and storytelling are among the top foundational skills necessary to “future-proof” your career over the next decade. That means your next presentation is too important to be left to chance. Practice the right way—under pressure—and you’ll shine when it counts.

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Overcoming Presentation Anxiety: Building Confidence and Conquering Your Fears

If you’ve experienced the pounding terror that comes before a crucial presentation, you’re not alone. Studies indicate 75% of adults are affected by a fear of public speaking.

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Presentation anxiety, which manifests as an unsettling mix of fear and dread, can greatly inhibit personal growth and career advancement. 

But it’s crucial to remember that this anxiety is not insurmountable.

This article is your guide to defeating presentation anxiety, replacing fear with confidence, and mastering the art of public speaking.

Recognizing and Managing Nervousness

Presentation anxiety manifests itself in various ways; these can be physical, such as a racing heart and sweaty palms, or cognitive, such as a blank mind or negative self-talk. Beneath these surface-level symptoms lie deeper underlying issues, often rooted in fear of failure or harsh judgment. Therefore, recognizing these elements is vital to mapping your journey toward overcoming presentation anxiety.

Understanding the root of your anxiety gives you the power to tackle it head-on. Is it the fear of public scrutiny, a past embarrassing experience, or the weight of high expectations? Once you identify the source, you can tailor your approach to manage it.

Now, on managing nervousness, it’s essential to note that eliminating anxiety isn’t the goal. Instead, the objective is to harness it constructively. Deep breathing exercises and progressive muscle relaxation can help regulate your physical response to stress. 

Finally, reframing anxious thoughts can lead to a more positive presentation experience. Instead of viewing the presentation as a dreaded event, see it as an opportunity to share valuable knowledge or insights with others.

Remember, feeling nervous is human. It’s an instinctive response to perceived challenges. The key is not to eliminate it but to manage, control, and channel it constructively.

Building Confidence through Preparation and Practice

Preparation is the bedrock of confidence . Begin by delving deep into your topic. Research gives you a solid understanding and arms you with additional information to handle unexpected questions. Once you’ve gathered your data, organize your ideas logically, ensuring your presentation has a clear and engaging flow.

With your content ready, turn to practice. Practice reinforces your familiarity with the material, allowing you to deliver it more naturally. Also, it enables you to identify potential pitfalls and address them proactively.

Today, technology enables you to use tools to record your presentation or you can practice in front of a mirror. Both strategies help you review and enhance your delivery style.

Remember that seeking feedback from trusted individuals can provide valuable insights into areas for improvement. Their perspective can help pinpoint parts of the presentation that may need more clarity, better engagement, or a different pace.

Using Relaxation Techniques Before Presenting

Relaxation techniques are excellent tools for mitigating pre-presentation stress. Let’s explore some of these techniques in detail.

First, progressive muscle relaxation involves sequentially tensing and relaxing different muscle groups. This procedure can assist you in achieving a profound level of relaxation and increasing your awareness of physical sensations. You can release tension before a presentation by starting at your toes and moving up to your head.

Another effective strategy is visualization. Imagine giving a presentation that is successful from beginning to end. Picture yourself confident, articulate, and engaging on stage, answering questions with ease and receiving applause at the end. This mental rehearsal primes your mind and body for a successful real-life performance.

Furthermore, mindfulness exercises help you stay present, focused, and calm, rather than getting caught up in future “what if” scenarios that fuel anxiety, mindfulness anchors you in the present moment. Simple practices like mindful breathing or a quick body scan can be done minutes before your presentation to calm your nerves.

Incorporating these techniques into a pre-presentation routine can provide stability and comfort, helping you transition into your presentation with reduced anxiety.

Overcoming Fear of Public Speaking

Public speaking fear, or glossophobia, affects many people but can be conquered with the right strategies and persistence.

One effective strategy is exposure therapy, where you gradually face your fear of public speaking. Start by giving a speech to a mirror, then a small, supportive group, and gradually increase the size of your audience as your confidence grows. The process helps to desensitize your fear response over time.

Moreover, positive visualization can be highly beneficial. This practice involves imagining yourself speaking confidently and receiving a positive response from your audience. Doing so can help reduce your fear and replace it with anticipation for a successful presentation.

Don’t forget that fear is often linked to perceived rather than actual threats. Reframing your perception of public speaking from a threat to an opportunity to share knowledge, influence others, and grow professionally can greatly reduce fear.

It’s also important to celebrate small victories along the way. Each step you take towards overcoming your fear of public speaking is progress worth acknowledging and celebrating.

Handling Unexpected Challenges and Technical Issues

In the realm of presentations, uncertainty is a given. Yet, being able to navigate unexpected challenges smoothly can set you apart as a confident and competent presenter.

Know that disruptions can come in many forms, including interruptions from the audience, environmental distractions, or technical difficulties. The key to handling these situations is maintaining composure and demonstrating adaptability.

If you’re interrupted, calmly acknowledge the interruption, address it if necessary, and then seamlessly return to your presentation. In the case of environmental distractions like noise, take a brief pause, allow the distraction to pass, and then continue.

Another common challenge, particularly in the era of virtual presentations, is technical issues. So, familiarize yourself with the technology you’ll be using and always have a backup plan, such as having your presentation saved on multiple devices or a printout for worst-case scenarios.

Lastly, remember that perfection is not the goal. Instead, aim for poise, adaptability, and resilience. Even the most experienced presenters face challenges; it’s how they handle them that makes them successful.

Overcoming presentation anxiety is a journey. It begins with recognizing and managing your nervousness, then building confidence through preparation and practice. Relaxation techniques can help reduce anxiety, while facing your fear of public speaking helps with personal growth. Lastly, developing the ability to handle unexpected challenges and technical issues gracefully will aid in honing your overall presentation skills.

Remember, with consistent effort, patience, and these practical strategies, you have what it takes to conquer presentation anxiety. You are capable of delivering compelling and confident presentations. The stage is yours to take, and the audience awaits your voice. So go ahead, embrace the opportunity, and shine.

About the Author

Nikole Pearson is a highly skilled environmental consultant with a diverse life sciences education. In the past 23 years, she has successfully managed and executed numerous environmental and regulatory projects across the western US. Nikole is a leading expert on utilizing AI for writing, editing, meeting management, presentation development, SEO, and social media management.

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How to Manage Public Speaking Anxiety

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Speech Anxiety and SAD

How to prepare for a speech.

Public speaking anxiety, also known as glossophobia , is one of the most commonly reported social fears.

While some people may feel nervous about giving a speech or presentation if you have social anxiety disorder (SAD) , public speaking anxiety may take over your life.

Public speaking anxiety may also be called speech anxiety or performance anxiety and is a type of social anxiety disorder (SAD). Social anxiety disorder, also sometimes referred to as social phobia, is one of the most common types of mental health conditions.

Public Speaking Anxiety Symptoms

Symptoms of public speaking anxiety are the same as those that occur for social anxiety disorder, but they only happen in the context of speaking in public.

If you live with public speaking anxiety, you may worry weeks or months in advance of a speech or presentation, and you probably have severe physical symptoms of anxiety during a speech, such as:

• Pounding heart
• Quivering voice
• Shortness of breath
• Upset stomach

Causes of Public Speaking Anxiety

These symptoms are a result of the fight or flight response —a rush of adrenaline that prepares you for danger. When there is no real physical threat, it can feel as though you have lost control of your body. This makes it very hard to do well during public speaking and may cause you to avoid situations in which you may have to speak in public.

How Is Public Speaking Anxiety Is Diagnosed

Public speaking anxiety may be diagnosed as SAD if it significantly interferes with your life. This fear of public speaking anxiety can cause problems such as:

• Changing courses at college to avoid a required oral presentation
• Changing jobs or careers
• Turning down promotions because of public speaking obligations
• Failing to give a speech when it would be appropriate (e.g., best man at a wedding)

If you have intense anxiety symptoms while speaking in public and your ability to live your life the way that you would like is affected by it, you may have SAD.

Public Speaking Anxiety Treatment

Fortunately, effective treatments for public speaking anxiety are avaible. Such treatment may involve medication, therapy, or a combination of the two.

Short-term therapy such as systematic desensitization and cognitive-behavioral therapy (CBT) can be helpful to learn how to manage anxiety symptoms and anxious thoughts that trigger them.

Ask your doctor for a referral to a therapist who can offer this type of therapy; in particular, it will be helpful if the therapist has experience in treating social anxiety and/or public speaking anxiety.

Research has also found that virtual reality (VR) therapy can also be an effective way to treat public speaking anxiety. One analysis found that students treated with VR therapy were able to experience positive benefits in as little as a week with between one and 12 sessions of VR therapy. The research also found that VR sessions were effective while being less invasive than in-person treatment sessions.

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If you live with public speaking anxiety that is causing you significant distress, ask your doctor about medication that can help. Short-term medications known as beta-blockers (e.g., propranolol) can be taken prior to a speech or presentation to block the symptoms of anxiety.

Other medications may also be prescribed for longer-term treatment of SAD, including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). When used in conjunction with therapy, you may find the medication helps to reduce your phobia of public speaking.

In addition to traditional treatment, there are several strategies that you can use to cope with speech anxiety and become better at public speaking in general . Public speaking is like any activity—better preparation equals better performance. Being better prepared will boost your confidence and make it easier to concentrate on delivering your message.

Even if you have SAD, with proper treatment and time invested in preparation, you can deliver a successful speech or presentation.

Pre-Performance Planning

Taking some steps to plan before you give a speech can help you better control feelings of anxiety. Before you give a speech or public performance:

• Choose a topic that interests you . If you are able, choose a topic that you are excited about. If you are not able to choose the topic, try using an approach to the topic that you find interesting. For example, you could tell a personal story that relates to the topic as a way to introduce your speech. This will ensure that you are engaged in your topic and motivated to research and prepare. When you present, others will feel your enthusiasm and be interested in what you have to say.
• Become familiar with the venue . Ideally, visit the conference room, classroom, auditorium, or banquet hall where you will be presenting before you give your speech. If possible, try practicing at least once in the environment that you will be speaking in. Being familiar with the venue and knowing where needed audio-visual components are ahead of time will mean one less thing to worry about at the time of your speech.
• Ask for accommodations . Accommodations are changes to your work environment that help you to manage your anxiety. This might mean asking for a podium, having a pitcher of ice water handy, bringing in audiovisual equipment, or even choosing to stay seated if appropriate. If you have been diagnosed with an anxiety disorder such as social anxiety disorder (SAD), you may be eligible for these through the Americans with Disabilities Act (ADA).
• Don’t script it . Have you ever sat through a speech where someone read from a prepared script word for word? You probably don’t recall much of what was said. Instead, prepare a list of key points on paper or notecards that you can refer to.
• Develop a routine . Put together a routine for managing anxiety on the day of a speech or presentation. This routine should help to put you in the proper frame of mind and allow you to maintain a relaxed state. An example might be exercising or practicing meditation on the morning of a speech.

Practice and Visualization

Even people who are comfortable speaking in public rehearse their speeches many times to get them right. Practicing your speech 10, 20, or even 30 times will give you confidence in your ability to deliver.

If your talk has a time limit, time yourself during practice runs and adjust your content as needed to fit within the time that you have. Lots of practice will help boost your self-confidence .

• Prepare for difficult questions . Before your presentation, try to anticipate hard questions and critical comments that might arise, and prepare responses ahead of time. Deal with a difficult audience member by paying them a compliment or finding something that you can agree on. Say something like, “Thanks for that important question” or “I really appreciate your comment.” Convey that you are open-minded and relaxed. If you don’t know how to answer the question, say you will look into it.
• Get some perspective . During a practice run, speak in front of a mirror or record yourself on a smartphone. Make note of how you appear and identify any nervous habits to avoid. This step is best done after you have received therapy or medication to manage your anxiety.
• Imagine yourself succeeding . Did you know your brain can’t tell the difference between an imagined activity and a real one? That is why elite athletes use visualization to improve athletic performance. As you practice your speech (remember 10, 20, or even 30 times!), imagine yourself wowing the audience with your amazing oratorical skills. Over time, what you imagine will be translated into what you are capable of.
• Learn to accept some anxiety . Even professional performers experience a bit of nervous excitement before a performance—in fact, most believe that a little anxiety actually makes you a better speaker. Learn to accept that you will always be a little anxious about giving a speech, but that it is normal and common to feel this way.

Setting Goals

Instead of trying to just scrape by, make it a personal goal to become an excellent public speaker. With proper treatment and lots of practice, you can become good at speaking in public. You might even end up enjoying it!

Put things into perspective. If you find that public speaking isn’t one of your strengths, remember that it is only one aspect of your life. We all have strengths in different areas. Instead, make it a goal simply to be more comfortable in front of an audience, so that public speaking anxiety doesn’t prevent you from achieving other goals in life.

A Word From Verywell

In the end, preparing well for a speech or presentation gives you confidence that you have done everything possible to succeed. Give yourself the tools and the ability to succeed, and be sure to include strategies for managing anxiety. These public-speaking tips should be used to complement traditional treatment methods for SAD, such as therapy and medication.

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Goldstein DS. Adrenal responses to stress . Cell Mol Neurobiol. 2010;30(8):1433-40. doi:10.1007/s10571-010-9606-9

Anderson PL, Zimand E, Hodges LF, Rothbaum BO. Cognitive behavioral therapy for public-speaking anxiety using virtual reality for exposure . Depress Anxiety. 2005;22(3):156-8. doi:10.1002/da.20090

Hinojo-Lucena FJ, Aznar-Díaz I, Cáceres-Reche MP, Trujillo-Torres JM, Romero-Rodríguez JM. Virtual reality treatment for public speaking anxiety in students. advancements and results in personalized medicine .  J Pers Med . 2020;10(1):14. doi:10.3390/jpm10010014

Steenen SA, van Wijk AJ, van der Heijden GJ, van Westrhenen R, de Lange J, de Jongh A. Propranolol for the treatment of anxiety disorders: Systematic review and meta-analysis . J Psychopharmacol (Oxford). 2016;30(2):128-39. doi:10.1177/0269881115612236

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

Microsoft 365 Life Hacks > Presentations > How To Calm Presentation Anxiety

Public Speaking: How to calm presentation anxiety

Fear of public speaking is one of the world’s most common phobias: An estimated 73 percent of people are affected by presentation anxiety, according to the National Institute of Mental Health.

So if your mind races and your stomach ties itself into knots every time you have to present information in front of others, you’re not alone.

It’s totally natural and it means you care. That said, there are time-tested, effective ways to learn how to calm those nerves before a presentation—and make them work to your benefit.

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1. Practice, practice, and then practice some more.

Most of us are not natural-born orators, which is why it’s so important to practice. Whether you’re giving a speech in person or presenting over a video call , knowing your material backward and forward is essential. Rehearsing in front of a mirror is good, but recording a trial run on your phone or computer is more helpful. Do you move your arms too much when you speak, bite your lip when you’re tense, or have a tendency to stare into space when grasping for the right word? Watching a recording of yourself, cringeworthy though it may feel in the moment, is the best way to assess your strengths and weaknesses and identify areas of growth. Run the recording through a transcription service and you’ll likely notice distracting speech tics like saying “um” and “like” excessively. Asking friends and family to listen to your pitch and offer constructive criticism is another way to beat the butterflies.

2. Write it out.

Worried you’ll flub your closing argument or forget an important statistic? It’s better to reference bulleted notes to keep yourself on track than to read off a teleprompter or quote your own slides. Fortunately, the simple act of writing out key talking points aids with memorization. The more you do it, the deeper your familiarity with the content will grow—and that will help you project confidence and ease when it’s showtime.

3. Put those nerves to work.

If you can’t banish nervous energy, channel it in a positive direction. Exercising a few hours before a big talk causes a rush of endorphins, which in turn makes you feel happier and more secure. To pump yourself up, blast upbeat music, dance with a partner (or pet!), jog in place or make a quick loop around the block, or grin like a maniacal clown until your face cracks a genuine smile. Audiences respond to enthusiastic presenters, so the trick is learning to be your own hype man/woman.

4. Avoid stimulants.

It may seem like a good idea to chug caffeine before a speech, but coffee, tea, soda, and neon-hued sports drinks can actually hinder your performance. Instead of looking bright-eyed and alert, you’ll titter and buzz like a chainsaw. Your hands will shake, your heart will pound, and you’ll feel extra jumpy. Alcohol, on the other hand, may take off the edge but also dulls it. Better to drink plenty of water, which will also help remedy dry throat and mouth, a common side effect of the adrenaline rush that comes before a presentation.

5. Arrive early.

The only thing worse than battling anxiety before a big presentation is running late. Whether you’re presenting in person or on a video call , showing up early gives you a chance to get your bearings. You can test your lighting and sound, chat with colleagues, perform breathing exercises, and, if time permits, do a dry run of your presentation. A quiet room or hallway is best, but a car or bathroom stall works in a pinch. (We’ve all been there.)

6. Just breeeeeathe.

Sometimes the easiest advice is the best. Breathing exercises can work wonders to soothe jangly nerves or help you regain composure if something throws you off-course. Apps like Headspace and Calm walk users through basic breathing exercises, or you can steel your nerves on your own by closing your eyes and focusing on your breath. On the count of three, inhale deeply through your nose for five seconds, filling your lungs with air. Hold for two or three beats, imagining every cell in your body ballooning with oxygen, and then release, exhaling slowly through your mouth. Repeat this five to ten times or until your heart rate drops back to earth and you’re feeling Zen-ish.

7. Picture brilliance.

The power of positive thinking—or positive visualization, as motivational speakers like to call it—is real. It’s a self-fulfilling prophecy of sorts, the idea being that if you picture something going your way, chances are it will. Next time you feel a crippling bout of stage fright coming on, imagine yourself on the podium or in the speaker box straight-up killing it.

Now that you’re feeling self-assured and eloquent, like a star TED talker, you’re ready for your next speech. This can end only one way, of course—with a standing ovation. Now, go out there and rock it for real.

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Nervous During Presentations? Reframe How You Think of Them

When you get anxious during a presentation, focusing on your feelings will only make things worse. Research shows that being kind and generous reduces our stress levels, so fight your nerves by thinking of your talk as an act of kindness: You’re sharing something valuable with other people. Use this framing when you’re preparing the […]

When you get anxious during a presentation, focusing on your feelings will only make things worse. Research shows that being kind and generous reduces our stress levels, so fight your nerves by thinking of your talk as an act of kindness: You’re sharing something valuable with other people. Use this framing when you’re preparing the presentation. Rather than starting with your topic, start with some reflection. Ask yourself, Who will be in the room? What do they need from me? Then craft a presentation that directly addresses those needs. On the day of your talk, when you’re extra nervous, take slow, deep breaths and remind yourself that you are here to help your listeners. And then during the presentation, connect with your audience by making eye contact — even if you’d rather do anything else. Pretend you’re having a series of one-on-one conversations, providing each person with the information they need. This generosity mindset can turn a painful experience into one of giving.

Source: This tip is adapted from “To Overcome Your Fear of Public Speaking, Stop Thinking About Yourself,” by Sarah Gershman

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Overcome your public speaking anxiety with these 10 tips

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What’s public speaking anxiety?

10 symptoms of public speaking anxiety, 10 common public speaking stressors, how to overcome public speaking anxiety: 10 tips, diagnosing and treating public speaking anxiety, speak with confidence.

Your opinion and expertise matter, so it can be frustrating when public speaking nerves leave you speechless. Maybe your heart races and you trip over your words, or you spend most of your presentation hoping no one asks questions. Fear not. Public speaking anxiety is a common experience that impacts even the most confident people — and it’s manageable.

The intense nerves associated with public speaking aren’t reserved for being on stage in front of a large audience. Discomfort might occur during small team presentations , a sales pitch with a client, or group brainstorming sessions . The stress may be so potent that you avoid important opportunities to showcase your expertise and advance your career. 

But identifying triggers and understanding your physiological response will help you overcome your anxiety. With practice and support, you’ll fearlessly share your important thoughts and opinions with others. 

Public speaking anxiety, or glossophobia, is the most common subset of social anxiety, affecting about 3–5% of the general population and 80% of people with social phobias . Those with glossophobia feel anxiety symptoms , like a racing heartbeat and stressful thoughts, when sharing ideas or asking questions in front of others. And those who experience public speaking anxiety often feel more general performance anxiety during activities like striking up a conversation with a stranger or eating in public.

But why does public speaking cause anxiety? According to an article by the Harvard Business Review, our ancestors perceived being watched as a predatory threat , so our brains evolved to have a fight-or-flight response . This is the body’s physiological response to danger, activating the nervous system to encourage us to return to safety.

While public speaking doesn’t present real physical dangers, social anxiety can trigger your stress response . Worrying about people judging you, making a mistake , or messing up an important professional opportunity are visceral fears that send messages to the brain to seek protection. 

In some cases, an acute fear can be motivating . Worrying about underperforming during a client presentation or making the right first impression at a face-to-face networking event could compel you to practice and perfect your speech. 

But a chronic and debilitating fear of public speaking can disrupt your career. You may become avoidant and miss important opportunities to show off your expertise, establish your personal brand , and achieve professional development goals . 

Publi c speaking anxiety is so all-encompassing you may not be conscientious of all the ways this type of stress affects the body. Acute anxiety symptoms are widespread and vary between people , but here are 10 common signs to be aware of:

Increased heart rate

Lack of concentration 

Avoidant behaviors like social isolation

Shortness of breath

Panic attacks

Intrusive thoughts

Shaky hands and legs

While you might associate public speaking anxiety with delivering a Ted Talk or corporate event presentation, plenty of everyday situations can trigger your fear of performing. Here are 10 common stressors of public speaking anxiety: 

Meeting new colleagues or coworkers

Job interviews

Sharing ideas in a brainstorming session

Giving a small presentation

Training new coworkers

Debriefing your team or managers on an ongoing project

Offering your opinion during a virtual meeting

Delivering an elevator pitch

Participating in a board meeting

Offering someone constructive criticism

Like any other challenge, thoughtful practice, care, and patience will help you approach public speaking confidently. Here are 10 tips for public speaking anxiety sufferers looking to improve.

1. Don’t expect perfection

Perfection is an unrealistic expectation that distracts from your good work and amplifies your anxiety. Instead of aiming for perfection , celebrate your improvements and seek out continuous learning opportunities . Every chance to speak in front of others is a chance to learn and grow — even if it means a few awkward pauses or stumbling over your words occasionally. 

2. Be yourself

While keeping your body language and humor professional, be your most authentic self and stick with what feels comfortable. Imitating others’ speaking styles could make you overthink each gesture or appear unnatural and insincere. And the more you step into your authenticity at work , the more comfortable you’ll feel being yourself in every area of your life. 

3. Remember your purpose

Whether delivering a presentation or making a sale, you’re speaking in public for a reason. Think about why you’re there — be it to share your experience or teach others — and focus on this core purpose. Doing so might get you out of your head and into the situation at hand so you can concentrate less on your anxiety symptoms and more on accomplishing your task.

4. Prepare and practice

The best way to feel comfortable speaking in front of others is to practice. Speech anxiety often focuses on the unknown, like audience questions or complex presentation materials. But subject-matter-familiarity quiets some of these questions and offers answers. 

You can jot down and prepare for questions you expect or memorize your materials so they feel less overwhelming. And p racticing your delivery and body language can take away the shock of talking to a group because you have less to worry about. 

5. Let your coworkers know

Consider informing coworkers and managers about your stage fright so they know to support you. They might make adjustments like offering you additional notice regarding presentations they’d like you to make or taking your questions last in a meeting so you have more time to calm your nerves. And you can also ask team members for feedback and encouragement on your public speaking skills . 

6. Visualize success

Use visualization , positive self-talk , and other manifestation methods to picture yourself confidently speaking in public. These positive projections can become a self-fulfilling prophecy as you do what’s necessary to make your vision a reality. You could also try anxiety journaling to shake negative automatic thoughts and track your positive thinking progress. 

7. Make eye contact

If you fear public speaking, you may instinctively avoid eye contact because it feels intimate or intimidating. But chances are everyone wants to encourage you, and you can feed off the room’s energy by looking your audience in the eye. If you see heads nodding and people paying attention, you may gain the confidence boost you need to continue nerves-free. 

8. Pose for success

Standing i n power poses (body postures expressing strength and assertiveness ) signals to audience members that you’re confident and comfortable. And embracing these postures can make you feel that way, too. For in-person speaking, try keeping your feet hip-distance and your shoulders back. And if you’re on a virtual call and have the option to stand, you can still carry yourself confidently to boost your own self-esteem. If you must sit, you can still hold your head high and posture straight. 

9. Create a plan

Feel in charge of your public speaking journey by creating an improvement plan. Start by outlining small objectives, like starting two conversations with colleagues each week or contributing an idea at a team meeting. Then, define larger goals further down your improvement timeline, like leading a brainstorming session or training a new coworker. You could also work with a career coach t o build the right plan for you and track your success.

10. Take a class

Structured learning might be the best way to reduce your public speaking anxiety and gain practice. Try asking your employer whether they subsidize professional development opportunities like a public speaking course or mentorship programs . Or invest in yourself by signing up for an after-hours class with a friend so you can hold each other accountable . 

According to the Diagnostic and Statistical Manual of Mental Disorders, public speaking anxiety is classified as a social anxiety disorder that causes symptoms like intense distress and panic attacks. While it’s common to feel nervous in social situations, a mental health professional might diagnose someone with public speaking anxiety if that person experiences symptoms that affect their day-to-day health, like missing out on job opportunities or having to leave a meeting due to nerves.

While social anxiety may feel overwhelming, the good news is that it’s treatable. The first step is finding a diagnosis. Treatment generally begins by identifying the root cause and any related medical conditions to ensure a larger issue isn’t causing your symptoms . Then, you’ll work with your mental health professional to determine the best treatment plan. Common remedies include psychotherapy, medication, or both. In some circumstances, you may also seek the help of a support group or work with a life coach to build an action plan . 

What you have to say matters, and you deserve to feel confident and comfortable when expressing yourself. While public speaking anxiety might quiet your voice, it doesn’t have to define your professional future. 

Now that you have some public speaking tips for anxiety, it’s time to start working toward easing your symptoms. Depending on the severity of your nerves, consider consulting with a mental health professional, career coach, or support group. From there, you can build an appropriate plan and begin speaking — one small speech at a time — with newfound confidence.

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Elizabeth Perry, ACC

Elizabeth Perry is a Coach Community Manager at BetterUp. She uses strategic engagement strategies to cultivate a learning community across a global network of Coaches through in-person and virtual experiences, technology-enabled platforms, and strategic coaching industry partnerships. With over 3 years of coaching experience and a certification in transformative leadership and life coaching from Sofia University, Elizabeth leverages transpersonal psychology expertise to help coaches and clients gain awareness of their behavioral and thought patterns, discover their purpose and passions, and elevate their potential. She is a lifelong student of psychology, personal growth, and human potential as well as an ICF-certified ACC transpersonal life and leadership Coach.

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Self-advocacy: improve your life by speaking up, speaking up for yourself is important — 11 steps to get it right, the 11 tips that will improve your public speaking skills, 8 tips to improve your public speaking skills, the importance of good speech: 5 tips to be more articulate, 7 strategies for how to stop yourself from spiraling, character references: 4 tips for a successful recommendation letter, 60 questions to ask to get to know someone, be brave even if you aren't yet (9 ways to conquer your fears), fear of public speaking overcome it with these 7 tips, how to not be nervous for a presentation — 13 tips that work (really), wondering what you're good at here are 10 ways to figure it out, 50 affirmations for anxiety to find inner peace, how the spotlight effect influences your experience of the world, power poses: how to feel more confident with body language, stay connected with betterup, get our newsletter, event invites, plus product insights and research..

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Here's How to Overcome Presentation Anxiety

By rob biesenbach, july-august 2020.

If you’re like most people, then you get nervous or anxious before a presentation. It’s OK. Even professional speakers go through this.

The difference is in how you manage it. You can let the anxiety drive you crazy and even affect your performance, or you can meet it head-on and at least subdue it, if not conquer it.

Billions of words have been written about overcoming stage fright. Beyond the usual menu of tactics, I’m going to offer a way to reframe your thinking, with a healthy dose of tough love.

But first, let’s clear the air on an important issue.

Bust a popular myth.

One little factoid that we hear all the time is that people fear public speaking even more than death. Death! 

But while that’s the premise of a memorable Jerry Seinfeld bit — “Now this means to the average person, if you have to go to a funeral, you’re better off in the casket than doing the eulogy” — nobody has found an actual study to support this claim.

I may be biased because I speak for a living but, personally, I would rather be up there doing the eulogy.

While some people suffer from truly debilitating anxiety that might require a deeper level of intervention, most people’s fear can be managed with a handful of simple tools. 

And, like I said, some tough love.

Check your ego at the podium.

When you explore the source of people’s speaking anxiety, it often comes down to the fear of making mistakes or looking dumb in front of colleagues or other people they need to impress. 

And some are self-conscious about their appearance or the sound of their voice.

For this group, I would say, “Get over it!”

Yes, get over it. That’s your ego talking. Your presentation is not about you, it’s about them — your audience.

Your only job is to provide useful information that will help them in some way, large or small — information that will lead them to change their thinking or even their behavior on a particular issue.

So set aside the notion of dazzling or impressing them. Turn the tables on your anxiety. Ask yourself, “How can I help today?” Show up to serve.

Manage your expectations.

Take note of the language I’m using here. It’s modest. Your impact may be small, but it’s useful. You will probably not rock their world and spark a 180-degree turnaround in their viewpoints or actions.

But if you can plant some seeds, give them some food for thought and prompt them to do some further exploration on an issue, then that’s a win.

While it’s true that a speech can change the world, most of them don’t. And they rarely, if ever, make that kind of impact entirely on their own.

So take the pressure off yourself and be modest in your ambitions.

Stop undermining your credibility.

We’ve all seen people visibly work themselves into a near-frenzy in the hours and days before a presentation, telling anyone and everyone how nervous they are. Maybe we’ve done it ourselves.

That’s a natural instinct — we’re talking things out and perhaps seeking reassurance that everything will be OK.

But beyond creating a self-perpetuating doom cycle of anxiety, this behavior seriously undermines your credibility as a professional.

Stop for a minute and think about the impression that you’re making on the people around you — those who look up to you and those who have a role in your future advancement.

This is about how we show up every day as professionals and as leaders.

Act like the leader you are.

When this issue comes up in my speeches and workshops, I often ask about that person’s regular, daily responsibilities. They walk through a few of the important things they do — managing budgets, counseling teammates, moving projects along.

Then I ask how they handle those duties. Do they conduct themselves with calm assurance, or do they run down the hallway like their hair is on fire?

Of course, it’s the former. The point is to treat a presentation like a normal part of your responsibilities. For PR pros, of course, communication is our job. But communication is the heart of everyone’s job, whether they’re managing teams, enlisting support for plans and initiatives, seeking compliance with policy or procedures, cultivating customer relationships or reassuring investors. 

So put yourself in the mindset that speaking in front of groups is simply one more of your normal duties and carry yourself accordingly. You’re cool, comfortable and contained.

In other words, you’re a leader.

Use the tactics for managing anxiety.

Those steps involve a major shift in thinking. Now let’s look at a few simple tactics that may be easier to implement:

• Understand your audience. What are their interests, needs, moods and objections? Use that insight to create truly relevant content and to forge a stronger connection. • Practice and prepare. There really isn’t a substitute for doing your homework and taking the time to practice. The better you know your material, the more poised and confident you will be. • Warm up. Before you go on, do some stretches to burn off excess energy, get your blood flowing and prepare your body. Take three deep breaths to calm yourself.

• Mingle (or don’t). Some speakers become energized by working the room beforehand — introducing themselves, getting to know audience members and asking questions. If you’re not wired that way, then that’s OK. Move on to the next step. 

• Focus. In the moments before you speak, put down your phone and think. Remind yourself of what you’re trying to accomplish and go through your intro in your head. That way, you’re more likely to hit the ground running and feel confident from the start. 

• Psych yourself up. Turn your nervousness into excitement. Convince yourself that you can’t wait to get out there, connect with people, share valuable information and make a difference — large or small — in people’s lives. • Ignore your mistakes. If you flub something, then keep going. The less you call attention to it, the less likely the audience will care or even notice. And silence your inner critic. Be cool.

Keep working at it.

Like anything else, the more you do it, the more you will improve. Many people have found Toastmasters to be a great way to get comfortable in front of groups. There are also plenty of books, training and coaching options to check out.

Put in the time to get better. Make it a priority. Yes, it’s a lot of work. But isn’t the benefit of relieving all of that anxiety worth it? photo credit: digitalvision vectors

Rob Biesenbach

Rob Biesenbach  helps leaders break free from death by PowerPoint, tell their story and communicate like humans should. He’s an in-demand speaker, workshop leader and coach, an award-winning communicator and a bestselling author. He’s worked with great organizations including AARP, Allstate, Caterpillar, Coca-Cola and Lockheed Martin.

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5 Tips for Overcoming Presentation Anxiety

Feeling jittery before a university presentation? You're in good company! In this article, Camila Franco, a Bachelor of Psychological Sciences (Honours) student at UQ, generously shares her expert tips on overcoming presentation anxiety. Get ready to transform from fearful to fearless with her invaluable advice!

Facing your classmates and delivering information that you've just learned, or are still mastering, can be a daunting task. I recall my first presentations vividly—when I didn’t have so much experience at public speaking, I felt my mouth extremely dry and started stuttering. My heart was pounding so hard, and my anxiety just became worse as I was looking to the public thinking they were judging me for my mistakes.

Here's the deal: even the most self-assured speakers can get a bit jittery before a presentation. A sprinkle of nerves can actually enhance our focus and keep us sharp. While that's somewhat comforting, there are effective strategies to tackle these pre-presentation jitters. But before we delve into those, let’s first gain a clear understanding of what presentation anxiety truly entails!

Understanding Presentation Jitters

The fear of public speaking often boils down to worrying about how the audience will perceive us. It's totally normal to stress over stumbling over words, forgetting what we're going to say, or feeling physically awkward like sweating or shaking. Recognising these signs of anxiety creeping up is the first step to handling them:

• Muscle tension
• Shaky hands
• Dry mouth, sweating, or blushing
• Upset stomach
• Feeling dizzy
• Catastrophic thoughts
• Trouble sleeping
• Heart racing or chest feeling tight

While these symptoms can feel overwhelming, they're definitely not unbeatable.

Let's dive into some tricks to help you prep and feel more confident when you're up against public speaking challenges.

Tip 1: Prepare a well-structured presentation

Success in public speaking begins with thorough preparation. Take the time to research your topic extensively and understand your audience's needs and expectations. Structure your presentation logically, and design visually engaging slides to support your message. Rehearse your script until you feel comfortable with its flow and content.

Tip 2: Polish and rehearse your script

Embrace a growth mindset and view challenges as opportunities for improvement. Practice delivering your speech aloud and use self-recording to evaluate your performance objectively. Seek feedback from friends or family members and incorporate their suggestions to refine your presentation. Familiarise yourself with the venue beforehand to alleviate any logistical concerns.

Tip 3: Challenge Negative Self-Talk

Identify and challenge the negative thoughts that contribute to your anxiety. Write down your concerns and the potential consequences you fear. Take a step back and assess whether these thoughts are realistic or exaggerated. Reframe negative self-talk with more balanced and empowering statements.

Tip 4: Create a Troubleshooting Plan

Anticipate potential challenges and devise strategies to address them proactively. For instance, keep a glass of water handy to combat dry mouth, or prepare standard responses for unexpected questions. Having a plan in place will boost your confidence and help you navigate any hurdles smoothly.

Tip 5: Practice Mindfulness

Incorporate relaxation techniques into your routine to manage anxiety effectively. Experiment with breathing exercises, visualisation, or meditation to calm your mind and body. Cultivate mindfulness habits that you can employ before, during, and after your presentations to stay grounded and focused.

When to Get Professional Help

If your presentation nerves are really starting to mess with your academic or personal life, it might be time to reach out for some extra support. Keep an eye out for signs like constantly avoiding presentations, messed-up sleep or eating habits, or weird physical symptoms that don't seem related to anxiety.

Consider chatting with a mental health pro or counsellor who can offer personalised advice and a listening ear. There are plenty of avenues of support you can turn to, including a range of programs and counselling services offered at UQ to help support students’ health and wellbeing.

Dealing with public speaking jitters is tough, but totally doable. Our university days are the perfect time to work on our presentation skills and boost our confidence. Push yourself a bit, tap into the resources around you, and you'll soon be rocking those speeches like a pro. Remember, every presentation is a chance to learn and grow.

Camila Franco

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Anxiety disorders

Experiencing occasional anxiety is a normal part of life. However, people with anxiety disorders frequently have intense, excessive and persistent worry and fear about everyday situations. Often, anxiety disorders involve repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks).

These feelings of anxiety and panic interfere with daily activities, are difficult to control, are out of proportion to the actual danger and can last a long time. You may avoid places or situations to prevent these feelings. Symptoms may start during childhood or the teen years and continue into adulthood.

Examples of anxiety disorders include generalized anxiety disorder, social anxiety disorder (social phobia), specific phobias and separation anxiety disorder. You can have more than one anxiety disorder. Sometimes anxiety results from a medical condition that needs treatment.

Whatever form of anxiety you have, treatment can help.

Common anxiety signs and symptoms include:

• Feeling nervous, restless or tense
• Having a sense of impending danger, panic or doom
• Having an increased heart rate
• Breathing rapidly (hyperventilation)
• Feeling weak or tired
• Trouble concentrating or thinking about anything other than the present worry
• Having trouble sleeping
• Experiencing gastrointestinal (GI) problems
• Having difficulty controlling worry
• Having the urge to avoid things that trigger anxiety

Several types of anxiety disorders exist:

• Agoraphobia (ag-uh-ruh-FOE-be-uh) is a type of anxiety disorder in which you fear and often avoid places or situations that might cause you to panic and make you feel trapped, helpless or embarrassed.
• Anxiety disorder due to a medical condition includes symptoms of intense anxiety or panic that are directly caused by a physical health problem.
• Generalized anxiety disorder includes persistent and excessive anxiety and worry about activities or events — even ordinary, routine issues. The worry is out of proportion to the actual circumstance, is difficult to control and affects how you feel physically. It often occurs along with other anxiety disorders or depression.
• Panic disorder involves repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks). You may have feelings of impending doom, shortness of breath, chest pain, or a rapid, fluttering or pounding heart (heart palpitations). These panic attacks may lead to worrying about them happening again or avoiding situations in which they've occurred.
• Selective mutism is a consistent failure of children to speak in certain situations, such as school, even when they can speak in other situations, such as at home with close family members. This can interfere with school, work and social functioning.
• Separation anxiety disorder is a childhood disorder characterized by anxiety that's excessive for the child's developmental level and related to separation from parents or others who have parental roles.
• Social anxiety disorder (social phobia) involves high levels of anxiety, fear and avoidance of social situations due to feelings of embarrassment, self-consciousness and concern about being judged or viewed negatively by others.
• Specific phobias are characterized by major anxiety when you're exposed to a specific object or situation and a desire to avoid it. Phobias provoke panic attacks in some people.
• Substance-induced anxiety disorder is characterized by symptoms of intense anxiety or panic that are a direct result of misusing drugs, taking medications, being exposed to a toxic substance or withdrawal from drugs.
• Other specified anxiety disorder and unspecified anxiety disorder are terms for anxiety or phobias that don't meet the exact criteria for any other anxiety disorders but are significant enough to be distressing and disruptive.

When to see a doctor

See your doctor if:

• You feel like you're worrying too much and it's interfering with your work, relationships or other parts of your life
• Your fear, worry or anxiety is upsetting to you and difficult to control
• You feel depressed, have trouble with alcohol or drug use, or have other mental health concerns along with anxiety
• You think your anxiety could be linked to a physical health problem
• You have suicidal thoughts or behaviors — if this is the case, seek emergency treatment immediately

Your worries may not go away on their own, and they may get worse over time if you don't seek help. See your doctor or a mental health provider before your anxiety gets worse. It's easier to treat if you get help early.

The causes of anxiety disorders aren't fully understood. Life experiences such as traumatic events appear to trigger anxiety disorders in people who are already prone to anxiety. Inherited traits also can be a factor.

Medical causes

For some people, anxiety may be linked to an underlying health issue. In some cases, anxiety signs and symptoms are the first indicators of a medical illness. If your doctor suspects your anxiety may have a medical cause, he or she may order tests to look for signs of a problem.

Examples of medical problems that can be linked to anxiety include:

• Heart disease
• Thyroid problems, such as hyperthyroidism
• Respiratory disorders, such as chronic obstructive pulmonary disease (COPD) and asthma
• Drug misuse or withdrawal
• Withdrawal from alcohol, anti-anxiety medications (benzodiazepines) or other medications
• Chronic pain or irritable bowel syndrome
• Rare tumors that produce certain fight-or-flight hormones

Sometimes anxiety can be a side effect of certain medications.

It's possible that your anxiety may be due to an underlying medical condition if:

• You don't have any blood relatives (such as a parent or sibling) with an anxiety disorder
• You didn't have an anxiety disorder as a child
• You don't avoid certain things or situations because of anxiety
• You have a sudden occurrence of anxiety that seems unrelated to life events and you didn't have a previous history of anxiety

Risk factors

These factors may increase your risk of developing an anxiety disorder:

• Trauma. Children who endured abuse or trauma or witnessed traumatic events are at higher risk of developing an anxiety disorder at some point in life. Adults who experience a traumatic event also can develop anxiety disorders.
• Stress due to an illness. Having a health condition or serious illness can cause significant worry about issues such as your treatment and your future.
• Stress buildup. A big event or a buildup of smaller stressful life situations may trigger excessive anxiety — for example, a death in the family, work stress or ongoing worry about finances.
• Personality. People with certain personality types are more prone to anxiety disorders than others are.
• Other mental health disorders. People with other mental health disorders, such as depression, often also have an anxiety disorder.
• Having blood relatives with an anxiety disorder. Anxiety disorders can run in families.
• Drugs or alcohol. Drug or alcohol use or misuse or withdrawal can cause or worsen anxiety.

Complications

Having an anxiety disorder does more than make you worry. It can also lead to, or worsen, other mental and physical conditions, such as:

• Depression (which often occurs with an anxiety disorder) or other mental health disorders
• Substance misuse
• Trouble sleeping (insomnia)
• Digestive or bowel problems
• Headaches and chronic pain
• Social isolation
• Problems functioning at school or work
• Poor quality of life

There's no way to predict for certain what will cause someone to develop an anxiety disorder, but you can take steps to reduce the impact of symptoms if you're anxious:

• Get help early. Anxiety, like many other mental health conditions, can be harder to treat if you wait.
• Stay active. Participate in activities that you enjoy and that make you feel good about yourself. Enjoy social interaction and caring relationships, which can lessen your worries.
• Avoid alcohol or drug use. Alcohol and drug use can cause or worsen anxiety. If you're addicted to any of these substances, quitting can make you anxious. If you can't quit on your own, see your doctor or find a support group to help you.

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How to Deal with Nerves Before a Presentation

Stop telling yourself to calm down..

Posted February 26, 2019

• What Is Anxiety?
• Take our Generalized Anxiety Disorder Test
• Find a therapist to overcome anxiety

There are a lot of situations that produce anxiety , but giving a presentation is quite possibly the most nerve-wracking of the professional workplace. it could be a presentation in a small meeting, or a pitch to the board, or an address to the whole company or a keynote speech at a conference. Whatever it is, standing in front of others and hoping you don’t forget your lines…or say them wrong…is a recipe for a high level of anxiety.

I get asked about nerves often because, well, most of my job is giving speeches . So, inevitably while I’m waiting backstage someone will ask, “Are you nervous? Do you still get nervous?” Or some variation of that question. And I reply the exact same thing every time.

I say no: I’m excited.

It’s not boastful; it’s actually me trying to hack my own psychology. Sure I get butterflies in my stomach, but I learned how to reframe them. A recent study by Alison Woods Burns of the Harvard Business School that looked at anxiety-producing situations and the best strategies to deal with them. Burns divided study participants into two groups and then exposed them to an anxiety-producing situation. She used a range of different situations, from singing karaoke to giving a presentation.

To the first group, she asked them to repeat the affirmation “I am calm” to try and soothe the participants' anxiety. She gave an affirmation to the second group, but it was very different: I am excited.

When she checked in after the fact, the “I am excited” group dramatically outperformed the “I am calm” group. They appeared to have a better experience. They actually felt like some of their anxiety lifted. And they gave a better presentation or sung better karaoke.

The theory behind why this works is that when you’re nervous, you feel a certain way. There are butterflies in your stomach. There’s a little shake to your hands. And if you try and calm yourself or lie to yourself and say you are calm, it's obvious that the affirmation doesn’t match your feelings. But nervousness and excitement feel very similar: Same butterflies. Same shake. Just a different way of understanding what your body is feeling. So you can re-frame the same sensation not as anxiety but as excitement. Excitement to get your message out into the world.

To push it even further, let’s be frank: If you knew you were going to give a terrible presentation then you wouldn’t be feeling nervousness, anyway. You’d be feeling dread. So the fact that you’re feeling nervousness means that there is a potential positive outcome. And that positive outcome is what you should focus on.

You’re not nervous that you won’t get that positive outcome, you’re excited because you can.

David Burkus is an assistant professor of management at the College of Business at Oral Roberts University.

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5 Practical Techniques for Harnessing Anxiety: Turning Leadership Stress into Success

Anxiety isn't a trigger--it's a signal..

You've probably seen (or even avoided) some stressful headlines recently. And it might not surprise you to learn that, according to the American Psychiatric Association's  annual mental health poll , 43 percent of US adults feel more anxious this year than last year. From skyrocketing inflation to a presidential election, the implications of AI, and more, the business world--and life in general, let's be real--is packed with stress. And because executives often shoulder tremendous pressure, here's something you or a leader you work with might need to hear today:

You can transform anxiety from a destructive force into a powerful catalyst for action. 

That's why I sat down with Marisa Valente, founder of The Center for Modern Workforce Strategy (MWS), to learn how leaders can leverage nervous energy to stimulate curiosity, dive deep into research, and make confident decisions that benefit the people we serve.

Understanding Productive Anxiety

Over the last seven years, mental health leaves of absence have  increased by 300 percent . Last year alone, mental health-related workplace absences increased 33 percent. 

A refreshed look at leadership from the desk of CEO and chief content officer Stephanie Mehta

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13 Affordable Items That Reviewers Say Actually Help Them De-Stress

On Assignment For HuffPost

Stress and anxiety are very much part of life, but that doesn’t mean you have to cope with these feelings alone. If you find yourself needing help in the decompressing department, we’ve compiled a list of mood-enhancing items on Amazon that you’ll look forward to incorporating into your wellness routine.

HuffPost and its publishing partners may receive a commission from some purchases made via links on this page. Every item is independently curated by the HuffPost Shopping team. Prices and availability are subject to change.

This aesthetically pleasing ultrasonic diffuser comes with a one-, three-, and six-hour timer and 10 essential oils to choose from, including calming lavender and uplifting eucalyptus. Promising review: "I suffer from anxiety and wanted to give this a try for relaxing at home. Holy cow. The little bubbling noise is so relaxing (sounds a little like a soda bubbling). The color changes are soothing. And the smell is strong and fantastic. My home felt like a spa. I love the lavender that came with it. Currently debating getting a second one for upstairs so I don’t have to move it so much. Take a chance and buy it. It’s great." — Lauren Christman

Having trouble staying focused while meditating? Enhance your practice with this plush velvet cushion that can make sitting more comfortable. Not to mention, the beautiful design on the cushion makes it a beautiful decor piece when not in use. Promising review: "This just what I needed. I’ve been doing a lot more meditation recently to try to alleviate symptoms of anxiety and stress. I was using anything else I could find that I thought would be suitable for a while but I found myself coming out of meditations with aches and pains which subsequently affected my mood and therefore made the meditation sessions seemingly redundant as I came out of the sessions feeling worse than I did going into them. I did some reflecting on this and realised that this was counter productive. Meditation is an investment in yourself and your wellbeing and there’s no use investing the time into it if you aren’t able to be comfortable while practicing it. Eventually, I did some research on options and found this meditation cushion. I thought I’d give it a try, not expecting a great deal of difference but attempting to keep an open mind. The difference, however, has been significant in a very positive way. I’ve been able to meditate comfortably, which allows me to relax and focus on breathing better... I like the fact it has a handle - sometimes I like to meditate outdoors for a change and it would be easy to take with me. It’s a good height off the ground, not too high and not too low which I think adds to the comfort it gives." — Ryan Garner (This review has been edited. Read the full review here .)

For people who respond well to tactile relief , these putty-like magnetic stones are oh-so-satisfying. Think of them like adult Play-Doh but without the mess, allowing you to roll, squeeze, and squish to your liking. Plus, they come in a metal tin so you can store them for future use or take them with you while traveling. Promising review: "I have bad anxiety as well as ADHD and use to use stress balls but kept breaking them. This is truly a game changer. The feel and sound alone is so relaxing but on top of that you don't end up with a mess!" — Jennifer

This guided journal is designed to bring awareness to any physiological stress or emotional anxiety you may be feeling. Its compact size also makes it a great therapeutic tool to stash in your daily bag for on-the-go jotting. Promising review: "I wasn’t sure what to expect from a guided journal, having never journaled before, but this came recommended to me by a friend. I tried it for the first time laying in bed unable to sleep with my own racing thoughts. I was pleasantly surprised to find that the exercises in the journal gave me a new sense of control of my anxiety. I was able to fall asleep promptly after closing the journal. I will continue to use this in hopes that I am able to restructure my thoughts in future times of worry and will recommend to others looking for help. — Goose

With up to 50 animal and floral pictures to choose from, you may end up reaching for this adult coloring book more than you will your phone. The pictures range from medium to intricate complexity, and they're one-sided to prevent any issues with bleeding. Promising review: "This is an absolutely beautiful book and exactly what I was looking for. Each animal picture is unique and the patterns are calming and easy to draw. I can feel myself slowing down as I use my pens until my tension is gone. You can pull back the spine, making it easier to tear away the pages (I color using a clipboard), the pages are nice and thick and the art is on only one side of the paper, so no worries about bleed-through. I highly recommend it!" — Lily Fisher

If you're curious about the effects of lavender on the quality of your sleep, this refreshing lemon and soothing lavender scent might be worth trying. Promising review: "This product was referred to me by a friend and let me tell you, I AM NOT DISAPPOINTED! Falling asleep is something that takes me a while but the calming scent of this mist has helped so much! Cut my time waiting to fall asleep in half! GREAT product!" — Rachel

If you'd like to experiment with the ingredient in your skin care, this lavender-infused body lotion is a promising choice. The silky formula keeps skin soothed, hydrated, and happy for up to 24 hours thanks to prebiotic oats, and the fact that it's non-comedogenic means it'll fare well with all skin types (oily included). Promising review: "I love this lotion. I was specifically searching for a lavender scented lotion to help with anxiety/stress. I’ve only used this for about 24 hours but it’s amazing enough for me to want to write a review. The smell is fantastic and my skin feels great. I put it on before bed last night and slept like a baby. It could be a coincidence but I doubt it. Regardless, if you’re looking for lavender lotion- it’s worth it." — Amarie3

Some say that an eye mask can be a major source of stress relief. This one can be used for both hot and cold therapy — just warm it up in the microwave or freeze it before popping it on and enjoying some relaxation time. Promising review: "I love this product. It really helps relax on those stressful days. I carry my tension around the eyes so when I saw this product I just had to try it out. Its very comfortable and well made. I have started recommending this product to my friends. Great when used cold for headaches and warm for relief from sinus issues too." — Amazon Customer

This set comes with seven tablets, each of which will last multiple shower sessions. Bonus: they make for a great stocking stuffer. Promising review: "This product has completely changed my shower experience, even my boyfriend noticed and appreciated it. It is so soothing and relaxing. It’s helped with our stress and anxiety. I highly recommend if you are looking for a way to make your shower experience more luxurious." — Deepika

It's no secret that a little self-care does wonders for your mood. Cue this facial roller set, which can set the tone for more a relaxed state of mind. Use it on your face, neck, shoulders, and back for a full-body experience. Promising review: "Love it when that cool jade rollerblade glides over the face…it instantly calms and soothes not only your face but your ‘peace of mind’ truly an ‘aaahhh’ moment!!!" — E. Hill

This puzzle features 300 pieces and an inspirational message, and can be done solo or with a loved one as a bonding activity. What's more, each purchase comes with a complimentary 30-day subscription to the Calm app. Promising review: "Beautifully crafted puzzle. I like that the CALM App is included free for 30 Days. You can find the corresponding nature sound/music that goes with the puzzle you are working on. 300 pieces. Definitely feel the benefit of doing puzzles and chillaxing." — Danielle Mazzaferro

Transform your bedroom into an intergalactic haven with this LED orb. Upon first glance it may look like nothing more than a night light, but its shape, design, and color changes — that the reviewer below described as “calming” — gives the illusion of movement. Promising review: "I just got the lamp today & I never write reviews. But I had to write a review for this one. It is amazing. The colors make you feel like you are in space and so calming. The remote is amazing too because you have such a wide array of colors to choose from as well as how you want the colors to appear. So do you want it to fade or flash etc. Amazing product." — Tida Martins

A chunky knit blanket is sure to bring the cozy vibes, but if you're looking to take things a step further, look to this weighted option, which is available in multiple weights, from eight to 22 pounds. It promises to deliver cloud-like comfort as it envelopes your body. Plus, it's machine washable. Promising review: "I got this in the king size. It’s a 25-pounds blanket which gives pressure that is distributed across your body and meant to simulate the feeling of being hugged. My husband and I have been using Nuzzie co for sleeping this past year and we LOVE it! And also, while we’re relaxing on the couch watching TV. Weighted blankets naturally reduce stress and increase relaxation through deep pressure stimulation. So comforting, so soft and luxurious - most importantly, we don’t feel overheated! If you need an additional relaxation tool, definitely give Nuzzie co a try!" — Silabans

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• Open access
• Published: 04 September 2024

Predicting anxiety treatment outcome in community mental health services using linked health administrative data

• Kevin E. K. Chai 1 ,
• Kyran Graham-Schmidt 2 ,
• Crystal M. Y. Lee 1 ,
• Daniel Rock 3 , 4 , 5 ,
• Mathew Coleman 6 ,
• Kim S. Betts 1 ,
• Suzanne Robinson 1 , 7 &
• Peter M. McEvoy 1 , 8  

Scientific Reports volume  14 , Article number:  20559 ( 2024 ) Cite this article

Metrics details

• Health care

Machine learning

• Psychiatric disorders

Anxiety disorders is ranked as the most common class of mental illness disorders globally, affecting hundreds of millions of people and significantly impacting daily life. Developing reliable predictive models for anxiety treatment outcomes holds immense potential to help guide the development of personalised care, optimise resource allocation and improve patient outcomes. This research investigates whether community mental health treatment for anxiety disorder is associated with reliable changes in Kessler psychological distress scale (K10) scores and whether pre-treatment K10 scores and past health service interactions can accurately predict reliable change (improvement). The K10 assessment was administered to 46,938 public patients in a community setting within the Western Australia dataset in 2005–2022; of whom 3794 in 4067 episodes of care were reassessed at least twice for anxiety disorders, obsessive–compulsive disorder, or reaction to severe stress and adjustment disorders (ICD-10 codes F40–F43). Reliable change on the K10 was calculated and used with the post-treatment score as the outcome variables. Machine learning models were developed using features from a large health service administrative linked dataset that includes the pre-treatment K10 assessment as well as community mental health episodes of care, emergency department presentations, and inpatient admissions for prediction. The classification model achieved an area under the receiver operating characteristic curve of 0.76 as well as an F1 score, precision and recall of 0.69, and the regression model achieved an R 2 of 0.37 with mean absolute error of 5.58 on the test dataset. While the prediction models achieved moderate performance, they also underscore the necessity for regular patient monitoring and the collection of more clinically relevant and contextual patient data to further improve prediction of treatment outcomes.

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Introduction.

Anxiety disorders are the most common class of mental illness in Australia, affecting 3.4 million adults aged 16 years and older or 17.2% of the population in 2020–2022 1 . Similarly in the United States, anxiety disorders are also the most common estimated to affect 30.6% of the population aged 18 years and older in 2020–2022 2 . These disorders are characterized by excessive worry, fear, and nervousness that can interfere with daily life. There are several different types of anxiety disorders, including generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobias. Historically, obsessive compulsive disorder and fear and stressor-related disorders (e.g., posttraumatic stress disorder) were considered anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association, APA, 1994) although more recent nosologies consider them separate but related classes of disorders (DSM-5, APA, 2013). Within the International Classification of Diseases (ICD version 10, 2019; ICD version 11, 2023), these disorders are three categories within the mental, behavioural or neurodevelopmental disorders.

Primary care is the main source of treatment for anxiety disorders and, where required, providers more commonly refer patients to private specialist services than to public services 3 . Nonetheless, community mental health services remain important for patients who cannot afford or access private providers 4 . Public services refer to government funded and operated specialised mental health care provided by community and hospital based ambulatory care services, such as outpatient and day clinics 5 and offer a variety of ongoing treatment options including psychotherapy, medication, and support groups. A continuing challenge for clinicians and services in all settings is to predict how well an individual will respond to treatment. There are many factors that can influence outcomes, such as the severity of the disorder, the patient's readiness for change, the quality of the treatment they receive, and external factors that reflect the overall complexity of human lives (e.g., relationship breakdown, financial hardship, workplace redundancy, bereavement) 5 , 6 , 7 .

Being able to accurately predict patient outcomes would be beneficial 7 , 8 , 9 , 10 . First, it would allow clinicians to tailor treatment plans to the individual needs of each patient, for example, by targeting known risk factors for disengagement or poor clinical outcomes. This could improve patient outcomes and reduce the need for patients to try multiple standardised treatments before finding one that works. Second, it would allow clinical planners in mental health services to allocate resources more effectively. For example, services could focus on providing more intensive treatment to patients who are at high risk of deterioration. Third, it could help identify patients who are unlikely to respond to treatment and may need additional support.

Promising methods for predicting patient outcomes for anxiety disorders and other mental illnesses include clinical prediction tools, patient-reported outcome measures, and machine learning 9 , 10 , 11 . These methods are commonly based on predictors such as patient demographics, clinical symptoms, treatment history, from different modes of data such as electronic health records, biometrics, and radiology and machine learning techniques such as logistic regression, random forests, support vector machines, gradient boosting and neural networks on datasets comprising of 4184 undergraduate students 9 and 1249 participants from a mental healthcare provider 11 .

Research on the prediction of treatment outcomes in mental health show that it is difficult, either because treatment outcomes genuinely do not vary based on individual differences or due to a range of methodological limitations, such as investigations of variables based on convenience rather than strong theory; the lack of consideration of the complex interplay between relational and content components of psychotherapy; low statistical power due to studies being designed to evaluate main effects of treatments rather than moderators of symptom change; overly homogenous samples due to exclusion criteria in randomised trials; over-reliance on significance testing without due consideration to effect sizes; failure to probe interactions to understand patterns of effects; and neglecting non-linear relationships within the context of complex relationships for humans in the real world 8 , 12 .

The alternative of relying on clinician intuition is also fraught. The biases clinicians bring to predicting psychotherapy outcomes have been long known 13 , 14 , 15 . Researchers have recently suggested that machine learning approaches that use large databases, theory-informed parameters and include complex relationships with multiple predictors of responder status, could address many of these issues 8 , 16 , 17 . Models that explain patterns in historical data and predict future outcomes, would hold promise for informing and improving the quality of care for people with anxiety disorders.

The aims of this study were to (a) investigate associations between demographic, treatment, and clinical variables and changes in psychological distress while patients were engaged with community mental health services and (b) develop machine learning models to predict reliable change in Kessler (K10) psychological distress scores using a patient’s pre-treatment (K10) scores within a community mental health setting and their past health service interactions for anxiety disorders. No previous research has used a large sample of demographic, clinical, and treatment service data administratively collected within community mental health services over a 17-year period to predict changes in psychological distress using machine learning models.

Study population

This study was approved by the Department of Health Western Australia Human Research Ethics Committee (approval number: RGS0000004782) and the Curtin University Human Research Ethics Committee (approval number: HRE2022-0001) with a waiver of informed consent obtained from the Department of Health Western Australia Human Research Ethics Committee. All methods in this study were performed in accordance with the relevant guidelines and regulations.

The study cohort was collated from a linked mental health dataset provided by the Department of Health Western Australia which is described elsewhere 18 . The linked dataset is comprised of records related to mental health assessments, community mental health service usage, emergency department presentations and inpatient admissions from 2005–2022.

For this study, we restricted the dataset to records from community mental health services where an anxiety disorder (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD): F40–F43) 19 was recorded at any time in the episode of care and to episodes of care with at least two assessments (pre and post treatment ≥ 2 weeks and ≤ 4 months apart) for determining the outcome of the treatment. Based on community mental health dataset collection rules, assessments are not to be reported for brief community interventions (< 2 weeks) and that assessments should be completed at least every three months (we adjusted to 4 months to allow delays and scheduling issues). Data is included from eligible patient episodes of care, with the first pre/post assessment used for each individual episode. Allowing multiple care episodes per patient better represents real-world conditions, providing a more accurate evaluation of the predictive model’s performance on each patient encounter. We conducted a sensitivity analysis comparing the use of single and multiple episodes of care in Supplementary Discussion 1 . ICD-10 was used as 99% of records in the community mental health data collection period within the study population used this classification.

The dataset preparation steps for defining the study population (Table 1 ) and the number of records from each anxiety disorder ICD-10 code (Table 2 ) are presented below.

Primary outcome measure

The K10 assessment is a self-reported measure of anxiety and depression symptoms characteristic of the broad construct of psychological distress 20 . It comprises of 10 questions about emotional states assessed on a five-level response scale (1 = none of the time, 2 = a little of the time, 3 = some of the time, 4 = most of the time, 5 = all of the time). The responses from the 10 questions can be summed to a total ranging from 10 to 50, where lower scores represent lower levels of distress. The K10 has high internal reliability (Cronbach's alpha = 0.93) 21 , distinguishes people with and without anxiety disorders 22 , and has been shown to be highly sensitive to change during psychotherapy 23 . We calculated Cronbach’s alpha for each ICD-10 code in our dataset using the Pingouin Python statistical package 24 .

Data analysis plan

Treatment outcome.

The treatment outcome and its effectiveness were determined by subtracting the post-treatment score from the pre-treatment score. Given that changes in scores reflect true change plus measurement error, Jacobson and Traux proposed the Reliable Change Index (RCI) to evaluate the effectiveness of therapies and interventions based on pre/post treatment scores 25 . The RCI estimates the magnitude of change in a measure’s observed score required before assuming that true change has occurred (i.e., not attributable to measurement error). The RCI is calculated by dividing the difference between the two scores by the standard error of the difference. RCI values ≥ 1.96 represent reliable improvement, RCI values ≤ 1.96 represent reliable deterioration and RCI values between − 1.96 and 1.96 represent no reliable change. The K10 was used as both a continuous outcome variable (post-treatment score) and to classify individuals with respect to whether they reliably improved, deteriorated, or remained unchanged between pre-treatment and post-treatment. The calculation of the RCI and subsequent analysis were conducted using Python 3.9.

The dataset of the study population was prepared with the prediction model features restricted to data from the K10 pre-assessment and previous community mental health episodes of care, in addition to emergency department and inpatient mental health service events (Fig.  1 ).

The data sources and features that are available for the prediction model at pre-assessment are depicted to the left of the dashed line. The first pre/post assessment is used for each episode of care and patients may have multiple eligible episodes of care in the dataset. ED emergency department.

The features extracted and created from these data sources are presented in Table 3 with definitions provided in Supplementary Table 1 . The dataset is split into a 70%/30% training and test set using fivefold random subsampling stratified cross validation in machine learning experiments.

Classification and regression models are used to predict the reliable change category (deterioration/no reliable change vs. reliable improvement) and post treatment score as a continuous variable, respectively. Models were trained using the Python scikit-learn library 26 . Training (70%) and testing (30%) datasets were created using a stratified fivefold repeated random sub-sampling cross-validation method.

Model selection

PyCaret 27 , an automated machine learning (AutoML) software library, was used to initially experiment with several machine learning algorithms by splitting only the training dataset into 70/30% using fivefold random sampling cross validation. These initial results will be used to select the most suitable classification and regression methods for subsequent experiments.

Model evaluation

The classification models are evaluated using the Receiver Operating Characteristic (ROC) Area Under the Curve (AUC), precision, recall, F1 score (harmonic mean of precision and recall) and a confusion matrix to identify how often a model gets predictions right (true positives/negatives) and wrong (false positives/negatives) for each reliable change category. An AUC of 1 is considered to have perfect predictive power while an AUC 0.5 suggests no predictive power beyond random chance 28 . The regression models are evaluated using predicted R squared (R 2 ) and the mean absolute error 29 . The predicted post-treatment scores from the regression model were also used to classify episodes of care into the reliable change categories for evaluation.

Feature importance and selection

Shapley Additive Explanations (SHAP) is a game theory inspired technique commonly used to explain the importance and contribution of features in prediction modelling 30 , 31 . It is a model agnostic approach applied to both classification and regression models in our experiments using the SHAP Python library 31 . Furthermore, a greedy forward feature selection method 32 was applied, which involved sequentially adding the feature that provides the largest contribution to the model until a pre-defined stopping criterion was met. The stopping criteria used in experiments for classification were F1 improvement > 0.01 and mean absolute error (MAE) improvement < 0.001 for regression.

The distribution of score changes between pre/post-treatment is shown in Fig.  2 . 2882 (71%) episodes of care showed a reduction in K10 score after treatment, 872 (21%) exhibited an increase in K10 after treatment and 313 (8%) remained unchanged.

The difference (score change) between pre/post treatment Kessler psychological distress scale (K10) total scores.

The RCI method was applied on the dataset, where K10 reliability coefficients (Cronbach's alphas) of 0.92–0.94 were calculated for each of the ICD codes. The pattern of reliable change for F43 (Reaction to severe stress, and adjustment disorders) is illustrated in Fig.  3 . These boundaries vary for other ICD codes (F40, F41, F42) as the reliable change index was calculated and applied separately for each diagnosis (Supplementary Fig.  1 ).

Pre/post treatment scores for F43: Reaction to severe stress, and adjustment disorders. The dashed green lines represent the boundaries of the reliable change index, with the area to the left representing reliable deterioration and the area to the right representing reliable improvement. The area between the green lines represents no reliable change.

Descriptive statistics for the dataset are reported in Table 4 . Altogether, 4067 episodes of care were available for analysis that comprised predominately of females (67%) and a mean (SD) age of 40.2 (17.9) years. The deteriorated reliable change category had low representation (212 records or 5%) and was merged with the no reliable change category (total of 2446 records or 60%) for machine learning experiments.

The machine learning results are presented in two sections (a) classification for predicting the reliable change category and (b) regression for predicting post-assessment scores.

Classification

PyCaret (AutoML) was used to initially experiment with several classification models on the training dataset using cross-validation as presented in Table 5 . Gradient boosting achieved the highest AUC (0.72) and F1 score (0.57). All the models outperform the baseline classifier (AUC = 0.5) that predicts all records as the majority class (deteriorated/no reliable change). Based on these results, gradient boosting was selected for subsequent experiments.

The gradient boosting model was run on both the train and test datasets achieving an average F1 score of 0.66 (0.66–0.69) over fivefold cross validation, with the best model achieving an AUC of 0.77 and F1 of 0.69 (Table 6 ).

The confusion matrix and ROC of the best model is presented in Fig.  4 . The confusion matrix highlighted that the model performed better in classifying episodes of care with deterioration/no reliable change (551 out of 734 (75%) correctly classified) than those that demonstrated reliable improvement (306 out of 487 (63%) correct).

( A ) Classification confusion matrix shows how often the model correctly predicted each class (true positives/negatives) and how often it made mistakes (false positives/negatives). ( B ) The receiver operating characteristic curve on the test dataset shows the sensitivity and specificity at different thresholds for prediction.

The top 20 features based on the SHAP values and feature selection results are shown in Supplementary Table 2 and Supplementary Fig.  2 . The top 2 features from both methods were the pre-assessment score and the collection stage (review). Only using the pre-assessment score achieved a 0.62 F1 score with the admission collection stage increasing the prediction performance to 0.66 and years since the previous emergency contact to 0.69. The additional 4 selected features only improve the model performance to 0.70 (+ 0.1 F1 score).

AutoML was applied to experiment with several regression models on the training dataset using cross-validation as presented in Table 7 . Gradient boosting achieved the top performance with a 0.33 R 2 and 5.82 MAE. All models, except for decision tree, outperformed the baseline regressor that predicts the mean post-treatment score for all records. The gradient boosting model was selected for subsequent experiments.

The gradient boosting model achieved an average MAE of 5.73 (5.58–5.83) over fivefold cross validation with the best model achieving an R 2 of 0.39, 0.37 and MAE values of 5.65, 5.58 on the train and test dataset, respectively (Table 8 ).

The top 20 features based on the absolute SHAP values and feature selection results are shown in Supplementary Table 3 and Supplementary Fig.  3 . Feature selection identified the pre-assessment score and the collection stage (admission) as the top features achieving a 5.75 and 5.59 MAE. The other 5 selected features only reduced the MAE to 5.52 (− 0.07).

Regression applied classification

The regression model predicted the post-assessment score and was used to classify episodes of care into reliable change. The regression applied classification results (Table 9 ) showed a decline when compared to the classification model with an F1 score of 0.69 vs. 0.67 on the test set. The AUC cannot be computed for comparison as the regression model does not generate classification probabilities.

The confusion matrix of the regression applied classification is shown in Fig.  5 . These results when compared to the classification model showed that the regression model performed poorer in predicting improved reliable change (306 vs. 304), and deterioration/no reliable change (551 vs. 533).

Regression applied classification confusion matrix shows how often the model correctly predicted each class (true positives/negatives) and how often it made mistakes (false positives/negatives).

This study aimed to investigate whether community mental health treatment is related to improvements in psychological distress and develop machine learning models for predicting reliable change and post-treatment scores in anxiety disorder treatments. The discussion will now assess whether the results and findings adequately achieved these aims.

Prediction performance

The classification model achieved an AUC of 0.76 on the test dataset of 1193 patients and an AUC between 0.75 and 0.90 indicates a moderate score in psychology and human behavioural research 33 , 34 . Our results are similar to a study that achieved an AUC of 0.73 on a test dataset of 1255 undergraduate students 9 and outperformed another study that achieved an AUC of 0.60 on 279 patients in their test dataset 11 . The regression model achieved a R 2 on the test dataset and a R 2 between 0.3 and 0.5 is generally considered a weak effect 35 but can be considered as moderate in the context of human behavioural and psychology research 36 . Furthermore, A MAE of 5.58 for the regression model could be interpreted as a relatively large error for downstream tasks such as using the predicted post-treatment scores to classify reliable change. The classification and regression applied classification model achieved similar performance and both outperformed the baseline models. The moderate performance indicates that the models could be further improved with more data and/or better discriminating features. However, there is likely to be an upper limit on prediction performance given the inherent complexity of human lives in predicting the outcome of patient treatments (i.e. Bayes error) 29 .

Classification and regression

The classification model generated probabilities for each class, which helped identify appropriate classification thresholds using the ROC and AUC evaluation metrics. However, a strength of the regression model is that it predicted the post-treatment score, which allowed for the use of classification systems such as reliable change and could potentially be used for other metrics of recovery. Furthermore, the SHAP values of the regression model were easier to interpret as a higher SHAP value indicated a higher predicted post-assessment score (poorer outcomes) compared to classification where a higher SHAP value represents as a lower post-assessment score (improved reliable change). For example, a high pre-assessment score (poor outcome) for classification resulted in the model predicting towards reliable improvement, possibly due to higher pre-assessment scores having more potential to change by post-assessment (i.e. lower scores experiencing a floor effect). However, for regression, a high pre-assessment score (poor outcome) would predict towards high post-assessment scores (poor outcomes).

Model features

The SHAP analysis and feature selection experiments showed that the pre-assessment score was the most important feature, with the assessment collection stage (admission, review) improving prediction with the remaining features providing only a minor contribution to the overall performance. However, a strength of having fewer contributing features is that the model is simpler to implement and translate into clinical software. These top features were, however, not particularly helpful for future treatment-matching, although the challenge of discovering robust predictors of mental health treatment outcomes is well known 8 , 12 . A shift from capturing predominantly health service activity data to capturing more clinically relevant data (e.g., therapeutic process, treatments delivered) along with contextual factors (i.e., non-therapy factors such as life stressors), and implementing more regular patient outcome monitoring 37 to more readily identify when a clinical intervention is not working and could be adapted or stopped, may be required to improve prediction. A cardiologist would not contemplate diagnosing and evaluating interventions for heart disease from single datapoints three months apart, and yet mental health services are expected to do so.

Clinically relevant data

While the study dataset can be seen as a strength (i.e. linked population dataset collected over a 17-year period for training and evaluating prediction models) it is still limited and can be further enhanced. The collection of administrative patient data is often driven by compliance and reporting requirements rather than a clear understanding of its clinical utility. This can lead to the accumulation of vast amounts of data that are difficult to analyse and interpret, providing limited insights into patient care and outcomes. Moreover, the focus on compliance can divert resources away from efforts to collect and curate data that is directly relevant to clinical decision-making while burdening clinicians with onerous data entry administrative tasks. For instance, measures of key individual differences theorised to play a critical role in the aetiology and maintenance of anxiety disorders, such as anxiety sensitivity 38 , intolerance of uncertainty 39 , and experiential avoidance 40 , may help with case formulation, treatment planning, and outcome monitoring. The degree to which interventions successfully modify these factors would be expected to determine downstream impacts on symptom change across the anxiety disorders. Patients’ satisfaction and engagement with the service (e.g., attendance frequency and duration), relational factors between the clinician and patient (e.g., working alliance 41 ), and social determinants (e.g., interpersonal supports and stressors, financial stressors, adverse childhood experiences 42 , 43 ) may also help focus clinicians’ and consumers’ attention on factors likely to have the largest impact on mental health and wellbeing and thereby improve outcomes and their prediction. Outcomes beyond symptom change that capture broader intervention impacts (e.g., quality of life), or monitoring progress on idiographic presenting problems (those specific and of highest priority to the individual), may be particularly valued by consumers 44 , although there is evidence that improvements in quality of life are largely mediated by symptom change 45 . Routine monitoring of known predictors of mental health and wellbeing would facilitate outcome evaluation and benchmarking, whereby novel interventions and service models can be compared over time to previous benchmarks. Without these data, services have no way of knowing if outcomes are worsening, maintaining, or improving over time, which would help with treatment planning. There is evidence that regular and routine outcome monitoring (e.g., session-by-session) that is used collaboratively by consumers and clinicians can improve outcomes, decrease negative outcomes for consumers at risk of not benefiting from treatment, and increase cost-effectiveness of interventions 46 . Future research incorporating and documenting these measures and processes would likely produce more robust and informative predictive models.

The inability of the prediction models to produce higher or more robust performance might suggest that the health administrative data being collected and made available for research lacks clinical relevance, which makes its collection and use difficult to justify. The resources invested in collecting and storing this data could be better utilised towards initiatives that directly improve patient care. Moreover, relying on data that fails to provide meaningful insights could lead to misguided policy decisions and interventions that may not produce the desired outcomes. Administrative data collected solely for service utilisation and planning metrics are insufficient for evaluating quality of care, identifying impacts of service innovations, and ensuring consumer outcomes improve over time. If the priority is maximising patient recovery, then infrastructure (e.g., digital platforms) and measures that routinely, regularly and effectively capture consumer-driven priorities are required to ensure interventions are on track for positive outcomes, or, if not, can be, collaboratively and rapidly responded to by the consumer and healthcare worker to process back on track.

Clinical assessment

A limitation of the model and experiments are features provided by clinicians in their assessments of the patients such as unstructured clinical notes. While these features could aid in prediction, it is noteworthy to highlight that it is also difficult for clinicians to predict, based only from the initial pre-assessment, whether a patient will drop out, be treatment resistant or improve. If this cannot be predicted accurately and reliably by clinical experts 13 , 14 , 15 , then it may be no different when developing and using predictive models. Future research including a combination of clinician, consumer, and administrative data may improve predictive models.

Predicting patient outcomes in mental health is a complex and difficult task but is essential for improving the quality of care for people with anxiety disorders. Research on the prediction of patient outcomes is ongoing and the preliminary findings to date are promising. This study developed classification and regression models that showed moderate prediction performance with features that would be relatively easy to collect and implement in health services organisations and clinics on a linked health administrative dataset collected over a 17-year period. Future research using regular patient outcome monitoring, clinical assessment, consumer and administrative data, may yield more accurate and reliable models for predicting patient outcomes. This will have a significant impact on the lives of people with anxiety disorders and will inform healthcare policy planning.

Data availability

The data that support the findings of this study are available from Government of Western Australia Department of Health ( https://www.datalinkage-wa.org.au/ ) but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. The corresponding author can provide clarification of the dataset used for the study but for access to the data, contact the Western Australia Department of Health at [email protected].

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Acknowledgements

This work was supported by the Digital Health Cooperative Research Centre (DHCRC) [DHCRC-0076]. DHCRC is funded under the Australian Commonwealth’s Cooperative Research Centres (CRC) Program. The funder had no role in the study design, data collection and analysis, decision to publish, or preparation for the manuscript. The authors wish to thank Justin Manuel from Western Australia Country Health Service for his ongoing contribution to the overall project and to the staff from the Department of Health WA’s Data Linkage Services and the Hospital Morbidity Data Collection, Emergency Department Data Collection, and Mental Health Data Collection.

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K.E.K.C analysed the data, conducted the experiments and drafted the manuscript. K.E.K.C, K.G.S C.M.Y.L, P.M.M., D.R, M.C conceived the design and P.M.M, K.G.S, D.R, M.C provided clinical advice for the project. K.S.B, P.M, D.R, S.R secured funding for the project. All authors contributed to the critical revision of the manuscript and approved the final version of the article to be published.

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Chai, K.E.K., Graham-Schmidt, K., Lee, C.M.Y. et al. Predicting anxiety treatment outcome in community mental health services using linked health administrative data. Sci Rep 14 , 20559 (2024). https://doi.org/10.1038/s41598-024-71557-2

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DOI : https://doi.org/10.1038/s41598-024-71557-2

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