Breaths to Calm

“Will I pass this exam?”

As a second-year medical student studying for the USMLE® Step 1 exam (The United States Medical Licensing Examination® is a three-part exam for medical licensure in the U.S.), I am reminded of the stress and anxiety I experienced before taking my MCAT® exam. In the days leading up to the MCAT exam, I remember feeling my mind racing, a nervous knot in my stomach, insomnia, and a feeling of dread. On the exam day, not only were these feelings amplified, but I also sensed similar emotions in my fellow test-takers fidgeting in their seats and expelling sighs of exasperation.

Despite all of this, I knew I had worked hard to study and was fortunate to do well. However, looking back, these exaggerated stress responses were actually very detrimental to my health and exam performance. However, at the time I did not know how to manage my feelings and physical response to this stress.

How do you let go of these overwhelming sensations so that you can change your experience?

Now, after being introduced to mind-body medicine as part of my medical education, I understand the beneficial effects of slow, deep breathing for stress reduction and improving focus.

I hope by sharing this information with others I can help them to lessen or alleviate some of the test taking anxiety that affects so many of us. I also wish to help others improve their academic performance.

What is Mind-Body Medicine?

Before discussing the effects of deep breathing, it is important to understand what mind-body medicine means. Mind-body medicine deals with the connection between our minds, behavior, and experiences. The techniques used utilize the ability of our thoughts and the physiological functions of our bodies to enhance our health and overall well-being. Mind-body medicine has been substantiated by decades of research.

I was first introduced to mind-body medicine when I joined a mind-body skills group as a medical student. I realized that in order to promote healthy lifestyle modifications to my future patients, I needed to make a change myself. The group was led by Dr. Jessica Singh, an emergency medicine attending that I had previously worked with as a scribe. I was given a scholarship to participate in the group.

The program is based upon the work of Dr. James Gordon and the Center for Mind-Body Medicine, and consists of 2-hour online weekly small group sessions. Each week we learned and practiced a different mind-body technique, such as meditation, breathwork, imagery, biofeedback, autogenics (a self-generating relaxation technique that involves attention-focusing exercises to induce relaxation and strengthen the body’s ability to self-heal), mindful eating, journaling, drawing, and dialoguing with emotions. I now incorporate these skills into my life and teach them to friends, family, and patients.

Diaphragmatic Breathing as a Mind-Body Approach

Diaphragmatic breathing, also known as abdominal breathing, engages the diaphragm to take full, deep breaths. (See the end of this post for notes on this type of breathing exercise.) It is a mind-body technique that can be used to lower stress by stimulating the vagus nerve, activating our parasympathetic nervous system, and causing a relaxation response.

When we are stressed, our autonomic nervous system (which consists of our sympathetic and parasympathetic nervous system) is hyperactive. With slow deep breathing, the heart rate and respiratory rate slow down, bringing balance to the autonomic nervous system.

How Does this Relate to Test Anxiety?

According to the American Psychological Association, test anxiety is the “tension and apprehensiveness associated with taking a test.” It “prevents one from demonstrating their true potential and thus lowers performance especially in the educational environment.” (Karatas, Alci, & Aydin, 2013)¹

Tests are a stressor, which can stimulate our fight or flight response and result in sweating, increased heart rate, rapid shallow breathing, elevated blood pressure, muscle tension, and flushed skin.  Often-overlooked effects of stress include racing thoughts, hypervigilance, or even “brain freeze” (the inability to recall information). 

The stress response is an evolutionary survival mechanism. However, in modern society, this physiological response most commonly occurs under non-life-threatening situations.

After a stress response, it is important that the body returns to baseline. The body always works to maintain a fixed internal environment, also known as homeostasis. Unfortunately, with chronic stress, the body does not return to a state of internal balance, which can lead to detrimental effects.

A study of medical students revealed that sources of test anxiety were related to cognitive “self-talk” such as perceiving the exam as “high stakes,” projecting prior academic performance to current and future exam-taking scenarios, time constraints, and comparison with peers.² In fact, studies have shown that approximately 50% of medical students suffer from problematic test anxiety.³ The psychological phenomenon known as anxious contagion, or the spread of anxious emotions from person to person, is also prevalent in the days leading up to an exam.

Can I Really Use the Breath to Alleviate Test Anxiety?

Diaphragmatic breathing is a widely utilized tool to relieve stress and increase self-empowerment. When employing this type of breathing, people are able to increase their recollection of information and remain calmer during a test.

In fact, mindfulness techniques have been shown to result in higher GRE scores, a decrease in mind wandering, and an increase in the working memory capacity of undergraduate students. Thus, mindfulness cultivation is an effective way to enhance cognitive performance.⁴

As a caveat, doing these types of breathing activities and other mindfulness techniques are not substitutes for knowing the material, but they can help to optimize a person’s performance.

You can experiment with diaphragmatic breathing now, and benefit from its calming effects. You can practice for just a couple minutes or as much as you want. The more you practice, the more you will see the results. Have gratitude for yourself and accept where you are right now.

Instructions for Practice

• Sit comfortably with your spine erect.
• Observe the natural pattern of your breath.
• Are you able to feel your heartbeat?
• Now, inhale deeply through the nose, noticing the abdomen expand. Then slowly exhale through the nose, the abdomen collapses.
• As you inhale, visualize the diaphragm contracting and moving downwards while the lungs expand with air.
• As you exhale, visualize the diaphragm relaxing, returning to its original dome shape, while the lungs deflate.
• Maintain a nice soft belly throughout each breath.
• Repeat this breathing for a few minutes, at your own pace with your eyes closed, if that’s comfortable for you.
• Observe the effects. How was this experience for you?

References

1) Karatas, H., Alci, B., & Aydin, H. (2013). Correlation among high school senior students test anxiety, academic performance and points of university entrance exam. Educational Research and Reviews, 8(13), 919-926.

2) Encandela, J., Gibson, C., Angoff, N., Leydon, G., & Green, M. (2014). Characteristics of test anxiety among medical students and congruence of strategies to address it. Medical education online, 19(1), 25211.

3) ​​Tsegay, L., Shumet, S., Damene, W., Gebreegziabhier, G., & Ayano, G. (2019). Prevalence and determinants of test anxiety among medical students in Addis Ababa Ethiopia. BMC medical education, 19(1), 1-10.

4) Mrazek, M. D., Franklin, M. S., Phillips, D. T., Baird, B., & Schooler, J. W. (2013). Mindfulness Training Improves Working Memory Capacity and GRE Performance While Reducing Mind Wandering. Psychological Science, 24(5), 776–781. https://doi.org/10.1177/0956797612459659

This post was co-authored by Dr. Jessica Singh. Jessica Singh, MD, is a Yale-trained Emergency Medicine physician who completed the first Physician Wellness fellowship in the Department of Emergency Medicine at Stanford University School of Medicine. She is the founder of Sukhayu Wellness, a wellness practice formed with the mission of helping individuals and organizations embrace natural wisdom to nurture health, humanity, and well-being. Sukh means peace and joy, and ayu means life in the Sanskrit language.