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Reducing Test Anxiety and Related Symptoms Using a Biofeedback Respiratory Practice Device: A Randomized Control Trial

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Abstract

Test Anxiety is a widespread psychological phenomenon. With prevalence rates of 20–40 percent of university students, it impedes adaptive functioning and life quality. Many available treatments for Test Anxiety involve the intervention of clinicians and usually a few months are required before symptom reduction is reported. The present randomized controlled trial examined a simple behavioral intervention—the use of breathing tools—as an exclusive therapy for Test Anxiety. Specifically, the efficacy of a biofeedback respiratory practice device was examined. 34 students were assigned to 3 treatment groups during their exam period: Biofeedback device group, self-directed breathing exercise group, and psychoeducation group. Self-report measures of Test Anxiety were collected pre- and post-intervention. Participants also reported additional exploratory measures such as depression and anxiety, quality of life, and their perceived adaptive functioning post-intervention. The results reveal that only participants from the biofeedback device group reported a significant reduction in Test Anxiety symptoms (p’s < 0.05). Participants from the biofeedback device group also reported a decrease in depression and anxiety symptoms and an increase in psychological wellbeing (p’s < 0.05), a subscale of the quality of life questionnaire. Findings support the notion that using biofeedback respiratory devices may reduce students’ Test Anxiety symptoms. Indications for further research are discussed.

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Acknowledgements

The authors thank Noa Kanter for writing assistance, technical editing, language editing, and proofreading.

Funding

Support for this study in the form of donating the product and paying for the language editor was provided by Dendro Technologies, Inc.

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Authors and Affiliations

  1. Baruch Ivcher School of Psychology, Herzlyia Inter-Disciplinary Center, 8 University Street, 4610101, Herzliya, Israel

    Amit Rosenberg & Daniel Hamiel

  2. Cohen-Harris Resillience Center, Tel-Aviv, Israel

    Daniel Hamiel

  3. Tel-Aviv-Brüll Community Mental Health Center, Clalit Health Services, Tel-Aviv, Israel

    Daniel Hamiel

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  1. Amit Rosenberg
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Appendices

Appendix 1

Test Anxiety Information Handout (Was Given to all the Participants)

Tests are an inseparable part of daily life in modern society. Our society is test-oriented, and exams serve as a means of decision-making in study and career processes throughout students’ lives. Therefore, it is not surprising that many experience significant levels of stress before exams. It is estimated that in the USA alone, more than 10 million elementary and high school students’ performances are impeded due to Test Anxiety. It is also estimated that 25%-30% of university students in the USA experience Test Anxiety. Test Anxiety predicts a broad spectrum of unwanted outcomes, such as lower cognitive performance, psychological distress, reduction in physical health and lower academic achievement. The term “Test Anxiety” refers to the psychological, physical, and behavioral reactions that stem from worry or physical arousal when one is concerned by the possible negative outcomes of failing a test. Test Anxiety may be triggered when people believe their intellectual abilities are being examined and questioned. Test Anxiety is a process that is affected by many factors, such as the specific test situation, anxiety traits of the subject, the ability to properly assess the possible threat, and the coping skills one has acquired to adjust to stressful situations.

Causes

Scientists today agree that a combination of a few factors contribute to the development of Test Anxiety

  • -Biological factors such as tendency to become anxious, learning disability, or attention deficits.

  • -Cultural or environmental factors such as high-achieving society.

  • -Personal factors, such as how one perceives the importance of a specific test or perfectionism.

How does Test Anxiety Develop?

The combination of the above-mentioned factors creates non-adaptive reactions when facing exam situations. These include physiological reactions, “black outs”, avoidance behaviors (procrastination) or on the contrary, over-studying and burn out.

How does Test Anxiety Influence Performance?

Whereas low levels of stress may increase emotional awareness and alertness and increase academic performance, high levels of stress significantly decrease the examinee performance. Examinees with low baseline levels of anxiety may find some stress helpful for their performance, whereas for examinees with high baseline levels of anxiety, even a small addition of stress caused by an exam may be harmful for their performance and wellbeing.

It was found that the worry aspect of Test Anxiety, e.g. the amount of negative thoughts an examinee experiences during a test, creates distraction, lowers the ability to focus, and hence impedes the performance on a test.

Treatment

According to the current findings, the most effective treatments for Test Anxiety combine behavioral and cognitive training with the acquisition of study skills.

Behavioral training refers to the teaching of relaxation skills that can assist an examinee to overcome “black outs” and remain calmer before and during the test.

Cognitive training refers to changing ones view of test and their implications when it comes to one’s personal life. Examinees are being taught to shift their attention to adaptive coping strategies (e.g. to study instead of worrying what will happen/constantly thinking about the importance of the specific test).

Study skills refer to learning better strategies for studying, such as planning breaks effectively and specific strategies to support different learning difficulties.

When anxiety levels are very high and influence many aspects of one’s life, medical treatment is considered as well.

The Correlation Between Stress and Performance

The effect of stress over performance is well-studied and many studies have come to the same conclusion: moderate levels of stress increase performance whereas high levels of stress reduce performance.

figure a

Appendix 2

Link to a Video with Instructions for Practicing Slow Breathing (was Provided only to the Participants from the Self-Directed Breathing Group)

https://www.youtube.com/watch?v=vVO5noRsS_Q.

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Rosenberg, A., Hamiel, D. Reducing Test Anxiety and Related Symptoms Using a Biofeedback Respiratory Practice Device: A Randomized Control Trial. Appl Psychophysiol Biofeedback 46, 69–82 (2021). https://doi.org/10.1007/s10484-020-09494-9

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