Case Study: Exam-related stress and anxiety among adolescent students


This study examined students coming out of 12th grade and entering professional college in the age range of 18 to 21 years. The transition from school to professional college in itself is a hectic process, involving the need for students to study day and night in order to perform well on the required entrance exams.

As the students’ studying becomes more complicated and vast, it requires more time and concentration. Each student has to prepare himself for the change. Often as the exam approaches, students’ levels of concentration and the study time involved increase. This, in turn, leads to more stress, and some students even develop anxious feelings in the form of palpitation, fine tremors, sweating, abdomen or chest pain, loose motion, etc. I had to deal with some students who went absolutely blank at the exam center, and when I took their history, I found that in the last 24-48 hours, they had slept for only one hour. In order to stay awake, they frequently consumed coffee. Very few students were also found to have amphetamines in their possession.

Inclusion criteria:

  1. Age range 18-21 years
  2. Both male and female included

Exclusion criteria:

  1. Prior history of psychiatric illness
  2. Prior history of drug abuse, particularly amphetamines
  3. Pregnancy


I was working in an institute hospital where 1500 students were staying in a hostel. I would see them for any medical problems and, besides this, the rest of my patients were faculty and employees of the company. I used to see students approaching me with problems of anxiety, and it was more frequent during exam time. I thought to evaluate them more deeply by understanding how they react to the stress of exams. I came across two categories of students: those who were studious throughout the year, consistently receiving good grades, and those who were only more active towards their studies during exam time, with grades varying from below average to good. The component of anxiety was present in both categories of students, but far less in studious students who maintained a good grade year-round. I even consulted the students’ teachers and received feedback on their performance in the classroom. We matched their signs and symptoms of anxiety to the proximity of exam times. Sometimes I would call the students’ parents and discuss with them their child’s academic performance and behavior in school and at home. This gave us a clearer idea of why such phenomenon is occurring, and then we planned our treatment strategies accordingly. Most of the students would compete with each other; if one were studying throughout the night, the other would try to follow him and go to sleep early in the morning. This may start a week before the exam.[s2If !is_user_logged_in()]…

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Case Presentation

Mild cases presented with dryness in the oral cavity and a feeling of fear to attend the exam. Moderate cases had fine tremors, palpitation, chest pain, abdominal pain and loose motion. Severe cases presented with going totally blank in the exam room; they could not make out the questions and what the exam was about.

As compared to males, the severity of symptoms was found to be more prominent in females. On the physical exam, except for tachycardia and sweating, the rest of the systemic examination was absolutely normal.


Complete blood count, EKG, and urine analysis were done to rule out any organic cause.


Non-pharmacological treatments given to each student with the problem were as follows:

  1. Counseling was given regarding sleep patterns. Students were advised to go to sleep at 11 PM and wake up early morning at 4 AM, so as not to miss stage 3, or the deep/delta part of their sleep.
  2. Transcendental meditation – Each student was taught 15 to 20 minutes of transcendental meditation, which would relieve him or her of any kind of stress, making the mind light and ready for the exam. They were to do this twice daily: first at 6 PM before dinner, sitting in a quiet atmosphere, and the second time, a half hour before going to the exam.
  3. They were advised to decrease their coffee intake.

Outcome and Follow-Up

There was drastic improvement in students’ anxiety symptoms. They felt light and energetic and were better able to concentrate on their studies.

My primary end point was that students would feel relaxed, with no sign of tachycardia, sweating or dryness of mouth. My secondary end point was grade evaluation.

With the help of their professor, we performed a grade assessment, which produced favorable results. Students had exams every 2 to 3 months, and when we took the average, these students scored 20 to 30% above their scores on earlier exams. Among girls and boys, girls scored 10% higher than boys.

In the professional university, since students had to undergo a very hectic schedule, we tried to fit this treatment into their regular habits. I was pleasantly surprised thereafter because I hardly received any students in my office with similar problems at exam time or any other time.


There are two types of sleep:

  1. Non-REM (rapid eye movement) sleep
  2. REM (rapid eye movement) sleep: In this type, a horizontal oscillation of the eyeballs takes place. The entire body is basically paralyzed, but the brain is active.

Deep sleep is the third stage of non-REM sleep, when a person’s electroencephalogram (EEG) will show delta waves. It is good for a person to have deep/delta sleep, as he/she feels active and relaxed upon waking up. I wanted students specifically to have this sleep stage so that they would feel energetic for the next day’s exam.

I taught transcendental meditation (TM) to all of the students with similar problems of stress and anxiety, and I encouraged not only the rest of the students, but all of my patients with co-morbidities of hypertension, anxiety-depression and coronary artery disease to learn and practice TM twice daily for 20 minutes.

TM helps in the following ways:

  1. It relaxes your mind.
  2. It brings down your basal metabolic rate (BMR), thus helping to relax your body. This can be assessed as your blood pressure and heart rate will decrease.

You can feel this change by feeling relaxed, rejuvenated, and full of energy. There has been much research conducted in other parts of the world with similar problems.

In one of the related studies, yoga was found to be more useful in relieving obsessive-compulsive disorder (OCD). (1) There was also a study done to investigate and assess the relationship between exam anxiety and test performance. It found a significant decrease in GPA with increased levels of exam anxiety. (2) Researchers at Walter Reed Medical Center are using Yoga therapy to relax patients with PTSD and plan to conduct further research. (3) Yogic breathing is useful in stabilizing the autonomic nervous system. A specific breathing technique can reduce stress and anxiety. (4,5,6)

Transcendental Meditation (TM) decreases psychological distress and blood pressure in young adults. This mind-body program may reduce the risk of future development of hypertension in young adults. (7)

Learning Points/Take Home Messages

Psychological imbalance or weakness may be related to our environment, our upbringing, and may have some genetic factor involvement. There are various means by which we can make our mind and body strong and influence our professional and emotional life.

We are in the midst of a highly competitive world, where one has to show his or her growth in order to stay ahead. To achieve this, one must learn to relax, and there are simple and effective ways to do so, such as a good night’s sleep and Transcendental Meditation.

One must develop a habit of going to sleep 2 hours before midnight, as it normally takes 30 minutes to an hour to achieve a good sleep. The TV should not be on in your bedroom. One can read before going to bed, and students must go to sleep at 11PM at the latest, to get the benefit of deep/delta sleep.

Transcendental Meditation helps to achieve deep relaxation. It should always be done on an empty stomach, in a quiet room because it brings down the respiratory rate and BMR to very low levels. TM should be done for at least 20 minutes twice daily at 7AM and in between 6-7PM.

This relaxation helps students to think clearly; whatever you study, you will be better able to retain it and be more energetic for the next day’s work. During exams, students can recall what they have read and get good grades.

About The Author

sarkarDr. Rajesh Sarkar is a Clinical Research Associate with Florida Family Physician and a permanent member of the Indian Medical Association. After completing his MBBS, he did DNB in Medicine, Post graduate certificate course in Psychiatry and Psychosexual medicine and Industry program in Clinical Trial Research and Administration from India. Later he joined the University of California, Santa Cruz to complete a post-graduate course in Clinical Trial Design and Management. He was working with Telome Health Inc., doing research on DNA telomere length in average healthy American population and its shortening (Length of Telomere) associated with different kinds of cancer.
anita sarkar1

Dr. Anita Sarkar, MBBS Lady Harding Medical College
Post Doctorate Certification In HIV/AIDS . Presently working on Breast Cancer and Cervical Cancer in young women.



References (click to show/hide)

  1. Yoga for anxiety: a systematic review of the research evidence. G Kirkwood, H Rampes, › Volume 39, Issue 12‎
  2. Lower academic performance due to test anxiety. Mark S. Chapell, Z. Benzamin, Journal of Educational Psychology 2005, Vol 97, No. 2, 268-274
  3. Yoga for anxiety and depression, Harvard Health Publication, Newsletter, APR 2009
  4. “Sudarshan Kriya Yogic Breathing in the Treatment of Stress, Anxiety, and Depression: Part I — Neurophysiologic Model,” (Feb. 2005) Brown RP, et al. Journal of Alternative and Complementary Medicine : Vol. 11, No. 1, pp. 189–201
  5. “Sudarshan Kriya Yogic Breathing in the Treatment of Stress, Anxiety, and Depression: Part II — Clinical Applications and Guidelines,” Brown RP, et al. Journal of Alternative and Complementary Medicine (Aug. 2005): Vol. 11, No. 4, pp. 711–17.
  6. Management of anxiety and hostility, Bhushan S, Sinha P. Yoganidra. Journal of Indian Psychology 2001; 19:44–49.
  7. “A randomized controlled trial on effects of the Transcendental Meditation program on blood pressure, psychological distress and coping in young adults.” Nidich SI et al. American Journal of Hypertension, 12: 1326-31, 2009.


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  1. jayesh vishariya
    Posted Feb 2014 at 12:14 pm | Permalink

    sir what is t m nd how to do it
    it is desireable if can narrat mathod

  2. jayesh vishariya
    Posted Feb 2014 at 12:16 pm | Permalink

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