pma review of treatment options

Reviews

Music performance anxiety (MPA) affects many individuals inde-pendent of age, gender, experience, and hours of practice. In orderto prevent MPA from happening or to alleviate it when it occurs, areview of the literature about its prevention and treatment wasdone. Forty-four articles, meeting evidence-based medicine (EBM)criteria, were identified and analyzed. Performance repertoireshould be chosen based on the musician’s skill level, and it shouldbe practiced to the point of automaticity. Because of this, the roleof music teachers is essential in preventing MPA. Prevention is themost effective method against MPA. Several treatments (psychologi-cal as well as pharmacological) have been studied on subjects inorder to determine the best treatment for MPA. Cognitive-behav-ioral therapy (CBT) seems to be the most effective, but further inves-tigation is desired. Some musicians, in addition to CBT, also take β-blockers; however, these drugs should only be prescribedoccasionally after analyzing the situation and considering the con-traindications and possible side effects. Despite these conclusions,more randomized studies with larger, homogeneous groups of sub-jects would be desirable (according to the EBM criteria), as well assupport for the necessity of both MPA prevention and optimizedmethods of treatment when it does occur. Med Probl Perform Art2011; 26(3):164–171.

Most forms of performance anxiety are difficult to treat,and anxiety levels after treatment rarely are reduced to

the levels of nonanxious people.1 The best form of treatmentis to prevent the occurrence of performance anxiety. Aware-ness of the availability of effective treatments for musicianswith performance anxiety should be introduced to studentmusicians at an early stage of their musical training. Soundpedagogy, appropriate parental support and expectations,and the learning of self-management strategies early in one’smusical education can help to mitigate the effects of enter-ing a highly stressful profession. Repeated exposure to thefeared situation (music performance) in the absence of thedevelopment of skills and strategies to ensure success is likelyto have a detrimental effect on the performer with poten-tially devastating consequences.2 Repertoire should be wellwithin the technical capacity and interpretative abilities ofthe student, and the material should be over-learned to thepoint of automaticity.1

Catastrophizing has been found to be the best predictor ofmusical performance anxiety (MPA),3,4 and an associationbetween arm stiffness and MPA has been reported.5 Bothfacts may contribute to the reason why cognitive-behavioralinterventions have proven to have good results in treatingMPA, as they focus on changing faulty thinking patterns thatgive rise to maladaptive behaviors, as well as changing thedysfunctional behaviors that arise when people feel anxious(with excessive muscle tension being the main symptom).6

In order to better understand MPA, a review of the dif-ferent treatment options was done, focusing on those thathave proven to be more effective: behavioral interventions,cognitive interventions, cognitive-behavioral interventions,combined interventions, others, and drug interventions. Atthe end of each section, conclusions regarding how the stud-ies were performed are provided. The studies were analyzedusing evidence-based medicine (EBM) criteria of Rosenbergand Donald.54 We have used the classification given byRichter, Zander, and Spahn7:

• Level I: Systematic review of randomized, double-blind, placebo-controlled trials. A meta-analysis combines the results of severalstudies that address a set of related research hypotheses.

• Level II: Evidence obtained from at least one properly designedrandomized controlled trial.

• Level III: Evidence obtained from well-designed controlled trialswithout randomization.

• Level IV: Evidence obtained from nonexperimental, nonran-domized trials.

• Level V: Opinions of respected authorities, based on clinicalexperience, descriptive studies, or reports of expert committees.

Relevant papers were identified by searching Medline andthe website archives of the journal Medical Problems of Per-forming Artists (www.sciandmed.com/mppa), as well as bymanual research for specific articles or authors familiar to theauthor. In addition, the references of these papers werescanned to identify other papers not found by the originalsearch. A total of 44 papers were identified that met the EBMcriteria I through V.

INTERVENTIONAL STUDIES

Behavioral Interventions (Table 1)

Behavioral therapies focus on changing the dysfunctionalbehaviors that arise when people feel anxious.6 One of the

164 Medical Problems of Performing Artists

Music Performance Anxiety—Part 2: A Review of Treatment Options

Ariadna Ortiz Brugués, MD, PhD

Dr. Brugues obtained her Doktor der Medizin from Albert-Ludwigs-Univer-sität, Freiburg, Germany. She is currently Medical Doctor at Hospital Uni-versitari Arnau de Vilanova, Lleida, Catalonia, Spain.

Address correspondence to Dr. Ariadna Ortiz Brugues, Prat de la Riba, 847º-4, 25004 Lleida, Spain. Tel +34 626203052. [email protected].

main symptoms that occurs is excessive muscle tension,which is treated with deep muscle relaxation training and sys-tematic desensitization. This is a procedure in which theperson is encouraged to imagine the anxiety-provoking situa-tion in graded steps, until they can visualize the situationwithout experiencing the muscle tension. Once the fear hier-archy has been mastered in the therapist’s office (imaginaldesensitization), people are encouraged to apply their newskills in the actual, anxiety-provoking situation (called “invivo” desensitization).

In all of the studies, behavioral interventions showed apositive effect on reducing performance anxiety, althoughthe kind of intervention often varied from one study toanother. Appel8 worked with systematic desensitization, asdid Wardle,9 who also introduced insight relaxation. Thislatter method, interestingly, resulted in greater heart ratereduction than systematic desensitization, although bothtreatments showed a reduction in anxiety behaviors com-pared to controls.

Kendrick et al.10 worked with students suffering fromMPA, creating two groups and utilizing behavior rehearsalsin one group and cognitive-behavioral therapy (CBT; basedon self-instruction, attention and focusing techniques) inthe other. The group treated with behavior rehearsalsshowed more improvement than controls on the Perfor-mance Anxiety Self-Statement Scale, as well as performancequality and visual signs of anxiety, while CBT showed moreimprovement on Expectations of Personal Efficacy. The pos-itive effects of CBT will be discussed further under thereview of CBT interventions.

Mansberger11 and Grishman12 worked with muscle relax-ation, which proved to positively affect self-efficacy and lowerscores on the Self-assessed State Anxiety Scale in the study byMansberger. Muscle relaxation also had a positive effect onthe State-Trait Anxiety Inventory state (STAI-S), symptoms,Music Performance Anxiety Questionnaire (MPAQ), andbaseline heart rate in Grishman’s report. Deen13 used aware-ness and breathing exercises, provoking a decrease on the Per-formance Anxiety Index (PAI). Esplen and Hodnett14 workedwith guided imagery exercises, demonstrating a decrease in

anxiety levels, but they found no relationship between thosepost-intervention anxiety levels and satisfaction with per-formance. Finally, Kim15 combined rhythmic breathing exer-cises, free improvisation, and desensitization exercises, reduc-ing performance anxiety.

Six of the eight studies analyzed in this category were ran-domized; only the ones by Esplen and Hodnett14 and byKim15 were nonrandomized trials. The number of subjectsthey used also differed; Kim15 studied an extremely small andhomogeneous sample (6 female college pianists), and Grish-man12 used a sample that was too diverse, with students andprofessionals in the same treatment group. There also weretoo many differences in each study measuring performanceanxiety in children, adolescent, and adults separately; thesame procedure should be performed when applying thera-pies in order to define more clearly the possible age differ-ences. The number and length of sessions as well as the scalesused also varied among the reviewed studies.

Behavioral therapies seem to have a positive effect onreducing performance anxiety. However, it would be desir-able to perform one randomized study with a large samplethat also considered age and possibly instrument differences.Another suggestion is to test different kinds of behavioralinterventions separately, while consistently using identicalconditions and scales.

September 2011 165

TABLE 1. Behavioral Interventions for MPA

Studies Evaluation Randomization* Study Design

Appel (1976)8 Level II R 30 graduate music students.Wardle (1969)9 Level II R 30 music students (brass players). 3 (groups) � 2 (time) repeated measures

design.Kendrick et al. (1982)10 Level II R 53 student pianists with MPA. 3 � 3 repeated measures design.Mansberger (1988)11 Level II R 19 music students. Simple 2 group comparison.Grishman (1989)12 Level II R 41 advanced music students and professionals. 2 � 2 repeated measures

design.Deen (1999)13 Level II R 39 music students. 2 � 2 repeated measures design.Esplen, Hodnett (1999)14 Level III NR 21 music students. Guided imagery exercise was used. STAI and LASA

(Linear Analog Self-Assessment) scale were used.Kim (2005)15 Level III NR 6 female college pianists. Effect of a Music Therapy Improvisation and

Desensitization Protocol (MTIDP) on alleviating performance anxiety.

*R, randomized; NR, nonrandomized.

GLOSSARY. Assessment Instruments Used in Studies

Abbreviation Measure

STAI-S State-Trait Anxiety Inventory ScaleLASA Linear Analog Self-AssessmentMTIDP Music Therapy Improvisation and Desensitization

ProtocolMPAQ Music Performance Anxiety QuestionnairePAI Performance Anxiety IndexMPASS Music Performance Anxiety ScaleSE Self-efficacyPQ Performance QualityWFPS Watkins-Farnum Performance ScalePRCP Personal Report of Confidence as a Performer

Cognitive Interventions (Table 2)

Cognitive therapy is more concerned with changing faultythinking patterns that give rise to maladaptive behaviors.6 Inthis type of therapy, people learn to replace negative, unpro-ductive, or catastrophic thinking with more rational, usefulways of perceiving their stressful situations.

Patson16 found no differences with the use of cognitive ther-apy. However, his study was only used on singers, and it wouldbe interesting to test cognitive therapy on instrumentalists. Alarger sample would also be desirable to detect any changes inthe results. A longer treatment period in both singing andinstrumentalist groups might also prove effectiveness.

Cognitive-Behavioral Interventions (Table 3)

CBT is a combination of behavioral and cognitive interven-tions.6 It helps people identify, analyze, and change counter-productive thoughts and behaviors, thereby alleviatingfeelings of depression and anxiety. Once these counterpro-ductive patterns are identified, the therapist instructs thepatient how to challenge and restructure their behavior andthinking. Behavior is based on rational, reality-based think-ing, rather than on negative, catastrophic thinking thatimpairs a person’s capacity to function properly.

These studies were mainly based on the use of self-instruc-tion, attention and focusing techniques, although there weredifferences among them. The three studies were randomizedwith an acceptable number of participants who were all stu-dents suffering from MPA.

The study by Kendrick et al.10 has already been analyzedunder behavioral interventions. Harris18 added relaxationtraining, imagery, and behavioral rehearsal to the use of self-instruction, showing a positive effect on performance anxietyas measured by both PAI and STAI-S scales, as well as ratedby teachers. This study also contained a follow-up, whichindicated maintained improvements in PAI and teacherrating but interestingly not STAI-S.

Roland19 performed two different studies: on the first onehe used self-instruction, progressive muscle relaxation, andcombination treatment. The results were an improvement onthe Music Performance Anxiety Scale (MPASS) for the com-

bined group, maintained on the follow-up, while self-instruc-tion showed pre-post improvement only, and muscle relax-ation showed an improvement on performance quality (bothon pre-post and follow-up). On the second study by Roland,19

a modified CBT was introduced as well as the standard CBT,but the results showed no difference between them. How-ever, when treatment groups were combined, they were supe-rior to controls on STAI, MPASS, Self-Efficacy (SE), but notPerformance Quality (PQ), at post-treatment and follow-up.Surprisingly, controls showed lower anticipatory heart ratethan both treatment groups.

There seems to be a positive effect in the use of CBT forreducing performance anxiety. Nevertheless, it would beinteresting to see how these techniques work on professionalmusicians, as well as differences between age groups.

Combined Interventions (Table 4)

Six of the seven studies analyzed in this category were ran-domized (one of the seven was a case report by Lazarus), withan appropriate number of subjects. They differed by usingstudents in some studies and professional musicians inothers.

The study by Sweeney and Horan20 was performed withstudents suffering from performance anxiety. Three differentgroups were made, applying either cue-controlled relaxation,cognitive restructuring, or both techniques combined.Results showed no differences among treatments, with all ofthem positively affecting performance anxiety. Interestingly,using cue-controlled relaxation and cognitive restructuringseparately led to lower pulse rates.

Nagel et al.21 also worked with students, while applying acombination of progressive muscle relaxation, cognitive ther-apy, and biofeedback training. This study showed reductionin performance anxiety.

Clark and Agras22 mixed students and professional musi-cians suffering from social phobia related to performance sit-uations. They formed three treatment groups: CBT plusplacebo, CBT plus buspirone, and buspirone alone. The con-trol group was given placebo medication. Results provedCBT to be more effective than buspirone in reducing per-formance anxiety. Furthermore, placebo groups showed a


TABLE 2. Cognitive Interventions for MPA


Patson (1996)16 Level II R 17 opera students. 3 � 2 repeated measures design.


TABLE 3. Cognitive-Behavioral Interventions for MPA


Kendrick et al (1982)10 Level II R 53 piano students with MPA. 3 � 2 repeated measures design.Harris (1987)18 Level II R 17 students with MPA. 2 � 3 repeated measures design.Roland (1993)19 Level II R 25 student pianists. 3 � 3 repeated measures design.


greater pre- to post-treatment fall in Self-Statement Ques-tionnaire than buspirone groups.

Niemann et al.23 used students with MPA, applyingbiofeedback sessions and group meetings (training in copingstrategies, muscle relaxation, breathing awareness, andimagery) as well as coinciding practice of the strategies withsedative music during individual biofeedback training. Thetreatment showed positive results for reducing anxiety. Brod-sky and Sloboda24 worked with professional symphonyorchestra musicians, using counseling, counseling plus relax-ation and listening to music, and counseling plus relaxationplus music and music-generated vibration sensations as ther-apies. Few differences between treatments were found, andthey showed improvements in anxiety and its symptoms.

Sweeney-Burton25 tested the effects of diaphragmaticbreathing, progressive muscle relaxation, autogenic training,and biofeedback on students, but results showed no improve-ment on anxiety. In the case report by Lazarus andAbramovitz,26 the subject responded very well to a focusedbut elaborate desensitization procedure, consisting of imagi-nal systematic desensitization, and sessions devoted to hisactual performance in the clinical setting. As a homeworkassignment, the patient found it helpful to listen to a long-playing record of an actual rehearsal and to play along withthe world-renowned orchestra and conductor.

In summary, combined therapies have proven to decreaseperformance anxiety, although not all of them have shownequal effectiveness. Once again, it would be desirable to haveone study that revealed the differences between students andprofessionals under exactly the same treatment regimen andduring the same period of time. Age group differences, aswell as possible variations in the results between singers andinstrumentalists, might also be of interest. Considering thelack of success in Sweeney-Burton’s studies,25 it would beinteresting to lengthen the amount of time with this therapy,while maintaining follow-up controls.

Other Interventions (Table 5)

There have been several attempts to prove the effectiveness ofcertain therapies on reducing performance anxiety. All of the

studies reviewed here were randomized, except the one byMerrit et al.35

McKinney27 studied the effects of biofeedback training on asample of music students in wind instruments. He foundgreater a pre- to post-treatment increase in Watkins-Farnum Per-formance Scale (WFPS), but no changes in either performanceanxiety or performance quality as evaluated by three judges.

Montello et al.28 tried group music therapy among asample of musicians with MPA. Results showed a positiveeffect in reducing MPA and in increasing musicality.Richard29 worked with students experiencing MPA, applyingEriksonian resource retrieval and cue-controlled relaxation.Results proved pre- to post-treatment improvement on theSTAI-S and Personal Report of Confidence as a Performer(PRCP) for the Eriksonian group. Stanton30 also workedwith students experiencing MPA, but the chosen treatmentwas hypnotherapy, which proved to have a positive effect inreducing performance anxiety, also in follow-up control.

Valentine et al.31 studied the effects of Alexander tech-nique in a group of students. Results showed that the treat-ment had positive effects in reducing some of the psychicaland physiological symptoms of performance anxiety. A meta-analysis study done by Saunders et al.32 indicated that stressinoculation training was an effective means for reducing per-formance anxiety. Gratto33 proved the effects of an auditionanxiety workshop on a sample of students, reporting that itprovided a better understanding of what causes audition anx-iety and helped students develop techniques to relieve audi-tion stress.

Chang34 found no differences in the use of meditation ona group of students compared to the control group. Merrit etal.35 tried a specialized vocal and physical skills training pro-gram among undergraduate performing arts students, show-ing a positive effect on both vocal and physical features, aswell as on perceived anxiety. Chang et al.36 found a positiveeffect of meditation in reducing performance anxiety in agroup of students. Furthermore, they reported an increase inrelaxation pleasure, even in the period immediately beforethe performance.

Valentine et al.37 tried to reduce stage fright in actors byassigning them either to South Indian techniques or to a neu-

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TABLE 4. Combined Interventions for MPA


Sweeney, Horan (1982)20 Level II R 49 music students with MPA. 5 � 2 repeated measures design.Nagel et al (1989)21 Level II R 20 music students with MPA. 2 � 2 repeated measures design.Clark, Agras (1991)22 Level II R 29 musicians (including full-time professionals) with social phobia (with

regard to performance situations). 4 � 2 repeated measures design.Niemann et al (1993)23 Level II R 18 music students with MPA. 2 � 2 repeated measures design.Brodsky, Sloboda (1997)24 Level II R 54 professional symphony orchestra musicians. 3 � 3 repeated measures

design.Sweeney-Burton (1998)25 Level II R 30 music students. 2 � 2 repeated measures design.Lazarus, Abramovitz (2004)26 Level IV NR Case report, focusing on a violinist in a symphony orchestra whose

career was in serious jeopardy because of extreme fear of performingin public.


rolinguistic program. Both therapies showed beneficialeffects in physiological as well as self-report measures. Over-all, the results favored the neurolinguistic program as havingmore potential as a therapeutic technique.

In summary, there appears to be a decent number of alter-native therapies that seem to reduce performance anxiety.However, there are too few studies performed to fully supportthe evidence reported by them.

Drug Interventions (Table 6)

The use of �-blockers to treat performance anxiety (referred toas stage fright by most of these authors) has been discussed formany years, and experts often present differing opinions. Allof the studies reviewed in this category were nonrandomized.

James et al.38 concluded that the use of oxprenolol in musi-cians improved musical performance overall seen on the firstperformance and in those subjects most affected by nervous-ness. Pearson and Simpson39 reported that oxprenolol causeda significant improvement in overall music performance.

Neftel et al.40 studied the effects of atenolol on string play-ers. Atenolol showed no significant effect on improving tech-nical-motor performance. It did not influence stage fright

measured before performing, but reduced it during the con-cert (measured immediately after the concert). Heart rate wassignificantly lower under ß-blockade than under placebo, andurine catecholamine levels increased twice as much under �-blockade as under placebo before an audience.

Brantigan et al.41 measured the effects of propanolol andterbutaline. They concluded that �-blockade eliminated thephysical symptoms of stage fright (even dry mouth) andimproved the quality of musical performance. However, �-blocker should only be used after consideration of the poten-tially detrimental effects on musical performance.

James et al.42 studied the effects of pindolol on professionalmusicians. They found a reduction in anxiety associated withan improvement in performance. Stress-related tachycardiaand increase in systolic blood pressure were attenuated.

James and Savage43 studied the effects of nadolol vs.diazepam in a sample of music students. Nadolol attenuatedthe rise in heart rate caused by anxiety and improved thoseelements of string playing that can be adversely affected bytremor. It also improved coordination and judgment. Noeffect on anxiety was noted for nadolol or for 2 mg diazepam.Diazepam, however, did cause some minor deterioration ofperformance that was not related to anxiety change.


TABLE 5. Other Interventions for MPA


McKinney (1984)27 Level II R 32 music students in wind instruments. 2 � 2 repeated measures design.Montello et al (1990)28 Level II R Freelance musicians with MPA: sample A, 17 subjects, and sample B,

24 subjects. A: 2 � 2 repeated measures design. B: 3 � 2 repeated measures design.

Richard (1992)29 Level II R 21 music students with MPA. 3 � 2 repeated measures design.Stanton (1994)30 Level II R 40 music students with MPA. 2 � 3 repeated measures design.Valentine et al (1995)31 Level II R 25 music students. 2 � 4 repeated measures design.Saunders et al (1996)32 Level I R 37 studies with 70 separate hypothesis tests, representing the behavior of

1837 participants.Gratto (1998)33 Level II R 92 music students from randomized selected members of the International

Network of Performing and Visual Arts Schools. Data were collected(interviews) before workshops were presented, on-site immediately following the workshops, and at a later date after an audition or juryexamination.

Chang (2001)34 Level II R 20 music students in piano, violin and voice. Post-test only, control group design.

Merrit et al (2001)35 Level III NR 18 undergraduate performing arts students divided into two even groups. At 10 weeks after the training period, both groups were videotapeddelivering a short speech, and the videotaped material was assessed byfour judges, using a visual analog scale.

Chang et al (2003)36 Level II R 19 students aged 18 to 41 yrs, recruited from the Manhattan School of Music, Mannes College of Music, Yale University School of Music, andSUNY Purchase.

Valentine et al (2006)37 Level II R 14 actors, with average of 5 yrs’ professional experience, for whom stage fright was a serious problem, were randomly assigned to a 4-day work-shop in either South Indian techniques (Siddha yoga, Kuttiyattam, andthe martial arts) or neurolinguistic programming (NLP, specific exerciseswere directed toward demonstrating that present problems are createdby the recollection of past emotions and toward teaching participantshow to control getting into high performance states.


Gates et al.44 reported the effects of different doses ofnadolol administered to a group of voice students. Resultsshowed that while the effects of low-dose �-blockade werehelpful, high doses may detract from performance ability.The study by Lehrer45 was a review which concluded that �-blockers were less effective for musicians experiencing morecognitive or psychological effects.

Berens and Ostrosky46 tested the effects of �-blockade ina group of both instrumentalists and singers. They con-cluded that �-blockade decreased tachycardia and improvedthe quality of the performance, but they also had seriousside effects (10% reported bradycardia, hypotension, coldextremities, gastrointestinal upset, sleep disturbance, ormuscle fatigue). The survey by Lockwood47 reported that27% of the orchestral musicians interviewed usedpropanolol to manage their anxiety prior to a performance,19% of them using it on a daily basis. Currie et al.48 analyzedthe positive and negative effects of captopril, oxazepam, andatenolol on memory and attention tasks. Capropril did notimpair performance on any of the tests but improved short-term memory, without affecting mood or subjective feelings.Oxazeparin reduced subjective alertness, and atenololincreased feelings of sleepiness.

Brandfonbrener,49 in an editorial, stated that the use of �-blockers must be individualized for each subject, and that itshould be combined with other psychological therapies. Led-

erman50 supported that �-blockers are very effective in coun-teracting tachycardia, sweating, and tremor, but also advisedof the side effects of these drugs. In the report, it is alsostated that instrumentalists who require more than occa-sional medication should probably consider alternativeapproaches; both medication and nonpharmacologic meth-ods may be used concurrently, if needed. Finally, Harris51

supported that research demonstrates successful alleviationof stage fright in orchestral musicians through the use of �-blockers, but no comparable data have been collected amongdance artists.

In summary, it can be concluded that the use of �-block-ade reduces some of the physiological symptoms of perform-ance anxiety. These drugs should be used only occasionally,and their use along with psychological therapies is highly rec-ommended. However, the use of �-blockers is not acceptedamong many singers and wind instrumentalists, because ithas been proven that they increase salivation.52

Doctors should analyze every single patient in order toknow if the drug should be prescribed to the subject or not,as well as consider the side effects of �-blockade. The recom-mended dose is 10 to 20 mg of propanolol taken 1 to 2 hrsbefore a performance53 (or 10 to 40 mg of propanolol taken60 or 90 min before performance50). It is recommended thatmusicians take a trial dose a few days before the event, inorder to familiarize themselves with the drug’s effects and to

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TABLE 6. Drug Interventions for MPA


James et al (1977)38 Level III NR 24 musicians with stage fright, assessing effect of 40 mg oxprenolol in a double-blind crossover trial.

Pearson, Simpson (1978)39 Level III NR 24 string players from the London colleges and academies of music. Double-blind trial: on the first day, 12 subjects took 40 mg ofoxprenolol and 12 took placebo; on the second day, the subjects whohad had oxprenolol on the first day received placebo and vice versa.

Neftel et al (1982)40 Level III NR 22 performing string players received 100 mg of atenolol or placebo 6.5 hr before performing, either in the presence or absence of an audience.

Brantigan et al (1982)41 Level II R 29 subjects (musicians), assessing effects of propanolol and terbutaline in a double blind study.

James et al (1983)42 Level III NR 30 professional musicians, assessing effect of 5 mg pindolol on stress-induced disturbances of performance.

James, Savage (1984)43 Level III NR 33 young music students. Effects of 40 mg nadolol vs 2 mg diazepam on performance anxiety of were determined in a double-blind, placebo-controlled, crossover design.

Gates et al (1985)44 Level III NR 34 singing students during end-of-semester juries, using a double-blind crossover paradigm. Students performed once with either placebo, 20,40, or 80 mg of nadolol, and again 48 hours later with placebo.

Lehrer (1987)45 Level I — ReviewBerens, Ostrosky (1988)46 Level III NR 150 musicians and singers.Lockwood (1989)47 Level IV NR Survey of 2,122 orchestral musicians at the International Conference of

Symphony and Opera Musicians (ICSOM).Currie et al (1990)48 Level III NR 14 healthy males, assessing central effects of single doses of captopril. Two

placebos, as well as oxazepam and atenolol, were included. Brandfonbrener (1990)49 Level IV — TheoryLederman (1999)50 Level V — TheoryHarris (2001)51 Level V — Theory


ensure that the normal anxiety about possible side effectsdoes not, itself, amplify the symptoms.53

CONCLUSIONS

As shown in Table 7, almost half of the studies analyzed inthis review were non-randomized. This makes the results lessreliable. Randomized studies are required.

The number of subjects investigated in these reports wasoften too small, and samples were sometimes too specific.Larger samples and from different areas (e.g., from differ-ent music schools, although from the same age group) arenecessary.

Another field of investigation could be reporting howMPA affects different musicians, depending on what instru-ment they play. It might be possible that those musicians whoplay instruments that require more mastery (e.g., violin,piano) would show higher levels of MPA. This hypothesis isbased on the fact that MPA varies among subjects, dependingon their perception about their capability of succeeding at aperformance. As has been shown, one of the first steps forthe prevention of MPA is choosing a repertoire that is withinthe musician’s ability. A musician who performs a repertoirethat he or she perceives as being extremely demanding willhave higher MPA scores. The same procedure could happenamong those who play instruments that require more mas-tery to be played well.

Finally, the advantages and disadvantages of medication(propanolol) vs. CBT in terms of time and money can besummed up as follows: the cost of propanolol, although itvaries from country to country, is around $0.50 (USD) perpill and should be taken 1 to 2 hrs prior to performing toachieve its effects. The cost of CBT is much higher and variesamong specialists, but the average of number of sessions is 4per week, 2 hours each time, for around 6 weeks. Neverthe-less, the advantages of medication are short-lived ones, withpossible side effects, whereas CBT has no side effects and theachievement is supposed to last much longer (as it is based oneducational and psychological interventions that put theindividual in charge of their own change process).

REFERENCES

1. Kenny DT, Ackermann B: Anxiety in public performance, stress andhealth issues for musicians. In: Hallam S, Cross I, Thaut M (eds):

Oxford Handbook of Music Psychology. Oxford, UK: Oxford Univer-sity Press; 2007.

2. Kenny DT: Negative emotions in music making—performance anxiety.In Juslin P, Sloboda J (eds): Handbook of Music and Emotion. Oxford,UK: Oxford Univ Press; 2008.

3. Zinn M, McCain C, Zinn M: Music performance anxiety and the high-risk model of threat perception. Med Probl Perform Art 2000;15(2):65-71.

4. Liston M, Frost AAM, Mohr PB: The prediction of musical perform-ance anxiety. Med Probl Perform Art 2003; 18(3):120-125.

5. Yoshie M, Kudo K, Ohtsuki T: Effects of psychological stress on stateanxiety, electromyographic anxiety, and arpeggio performance inpianists. Med Probl Perform Art 2008; 23(3):120-132.

6. Kenny DT: Treatment approaches for of musical performance anxiety—what works? Music Forum 2004; 10(4):38-43.

7. Richter B, Zander M, Spahn C: Gehörschutz im Orchester. FreiburgerBeiträge zur Musikermedizin 2007; 4:16-17.

8. Appel S: Modifying solo performance anxiety in adult pianists. J MusicTher 1971; 3:2-16.

9. Wardle A: Behavior modification by reciprocal inhibition of instru-mental of musical performance anxiety. Res Music Behav 1969; 191-205.

10. Kendrick MJ, Craig KD, Lawson DM, Davidson PO: Cognitive andbehavioral therapy for of musical performance anxiety. J Consult ClinPsychol 1982; 50:353-362.

11. Mansberger NB: The effects of performance anxiety managementtraining on musicians’ self-efficacy, state anxiety and musical perform-ance quality [doctoral dissertation]. Western Michigan University,1988.

12. Grishman A: Musicians’ performance anxiety—the effectiveness ofmodified progressive muscle relaxation in reducing physiological, cog-nitive, and behavioral symptoms of anxiety. Dissert Abstr Int 1989;50(6-B): 2622.

13. Deen DR: Awareness of breathing: keys to the moderation of of musi-cal performance anxiety [doctoral dissertation]. University of Ken-tucky, 1999.

14. Esplen MJ, Hodnett E: A pilot study investigating musicians’ experi-ences of guided imagery as a technique to manage performance anxi-ety. Med Probl Perform Art 1999; 14(3):127-132.

15. Kim Y: Combined treatment of improvisation and desensitization toalleviate of musical performance anxiety in female college pianists.Med Probl Perform Art 2005; 20(1):17-24.

16. Patson T: Performance anxiety in opera singers [master’s thesis]. SydneyConservatorium of Music, 1996.

17. (reference deleted).18. Harris DA: Brief cognitive-behavioral group counselling for musical

performance anxiety. J Int Soc Study Tension Perform 1987; 4:3-10.19. Roland DJ: The development and evaluation of a modified cognitive-

behavioral treatment for musical performance anxiety. Dissert AbstrInt 1993; 55(5-B):2016.

20. Sweeney GA, Horan JJ: Separate and combined effects of cue-con-trolled relaxation and cognitive restructuring in the treatment of musi-cal performance anxiety. J Counsel Psychol 1982; 29:486-497.

21. Nagel JJ, Himle DP, Papsdorf JD: Cognitive-behavioral treatment ofmusical performance anxiety. Psychol Music 1989; 17:12-21.

22. Clark DB, Agras WS: The assessment and treatment of performanceanxiety in musicians. Am J Psychiatry 1991; 148:598-605.

23. Niemann BK, Pratt RR, Maughan ML: Biofeedback training, selectedcoping strategies, and music relaxation interventions to reduce debili-tative musical performance anxiety. Int J Arts Med 1993; 2:7-15.

24. Brodsky W, Sloboda JA: Clinical trial of a music generated vibrotactiletherapeutic environment for musicians—main effects and outcome dif-ferences between therapy subgroups. J Music Ther 1997; 34:2-32.

25. Sweeney-Burton C: Effects of self-relaxation techniques training of per-formance anxiety and on performance quality in a music performancecondition. Dissert Abstr Int 1998; 58(7-A):2581.

26. Lazarus AA, Abramovitz A: A multimodal behavioral approach to per-formance anxiety. J Clin Psychol 2004; 60(8):831-840.

27. McKinney HV: The effects of thermal biofeedback training on musicalperformance and performance anxiety [doctoral dissertation]. Univer-sity of Northern Colorado, 1984.

28. Montello L, Coons EE, Kantor J: The use of group music therapy as atreatment for musical performance stress. Med Probl Perform Art1990; 5(1):49-57.

29. Richard JJ: The effects of Ericksonian resource retrieval on musicalperformance anxiety. Dissert Abstr Int 1992; 55(2-B):604.


TABLE 7. Number of Studies Evaluated by EBM Level

Level______________________Elements I II III IV V

Behavioral interventions 0 6 2 0 0Cognitive interventions 0 1 0 0 0Cognitive-behavioral interventions 0 3 0 0 0Combined interventions 0 6 0 1 0Other interventions 1 9 1 0 0Drug interventions 1 1 8 2 2

Totals 2 26 11 3 2

30. Stanton HE: Reduction of performance anxiety in music students.Austr Psychol 1994; 29:124-127.

31. Valentine E, Fitzgerald D, Gorton T, et al: The effect of lessons in theAlexander technique on music performance in high and low stress sit-uations. Psychol Music 1995; 23:129-141.

32. Saunders T, Driskell JE, Johnston JH, Salas E: The effect of stressinoculation training on anxiety and performance. J Occup Health Psy-chol 1996; 1(2):170-186.

33. Gratto SD: The effectiveness of an audition anxiety workshop inreducing stress. Med Probl Perform Art 1998; 13(1):29-34.

34. Chang JC: Effects of meditation on musical performance anxiety. Dis-sert Abstr Int 2001;AAT 3014754.

35. Merrit L, Richards A, Davis P: Performance anxiety—loss of the spokenedge. J Voice 2001; 15(2):257-269.

36. Chang JC, Midlarsky E, Lin P: Effects of meditation on musical per-formance anxiety. Med Probl Perform Art 2003; 18(3):126-130.

37. Valentine ER, Meyer-Dinkgräfe D, Acs V, Wasley D: Exploratory inves-tigation of South Indian techniques and neurolinguistic programmingas methods on reducing stage fright in actors. Med Probl Perform Art2006; 21(3):126-136.

38. James IM, Griffith DN, Pearson RM, Newbury P: Effect of oxprenololon stage fright in musicians. Lancet 1977; 2:952-954.

39. Pearson RM, Simpson A: Effect of oxprenolol in stage fright in musi-cians. Trans Med Soc Lond 1978; 79(95):46-53.

40. Neftel KA, Adler RH, Kappeli L, et al: Stage fright in musicians—amodel illustrating the effect of ß-blockers. Psychosom Med 1982;44(5):461-469.

41. Brantigan CO, Brantigan TA, Joseph N: Effect of ß-blockade and ß-stimulation on stage fright. Am J Med 1982; 72(1):88-94.

42. James IM, Burgoyne W, Savage IT: Effect of pindolol on stress-related

disturbances of musical performance—preliminary communication. JR Soc Med 1983; 76:194-196.

43. James I, Savage B: Beneficial effect of nadolol on anxiety-induced dis-turbances of performance in musicians—a comparison with diazepamand placebo. Am Heart J 1984; 108:1150-1155.

44. Gates GA, Saegert J, Wilson N, et al: Effect of beta-blockade on singingperformance. Ann Otolaryngol Rhinol Lanryngol 1985; 94:570-574.

45. Lehrer PM: A review of the approaches to the management of tensionand stage fright in music performance. Med Probl Perform Art 1987;14(3):117-121.

46. Berens PL, Ostrosky JD: Use of beta-blocking agents in musical per-formance induced anxiety. Drug Intell Clin Pharm 1988; 22:148-149.

47. Lockwood AH: Medical problems of musicians. N Engl J Med 1989;320:221-227.

48. Currie D, Lewis RV, McDevitt DG, et al: Central effects of theangiotensin-converting enzyme inhibitor, captopril. Br J Clin Pharma-col 1990; 30:527-536.

49. Brandfonbrener AG: Performance anxiety: “different strokes for dif-ferent folks” [editorial]. Med Probl Perform Art 1999; 14(3):115.

50. Lederman RJ: Medical treatment of performance anxiety. Med ProblPerform Art 1999; 14(3):117-121.

51. Harris SR: Using ß-blockers to control stage fright: a dancer’sdilemma. Med Probl Perform Art 2001; 16(2):72-76.

52. Sataloff RT, Rosen DC, Levy S: Medical treatment of performance anx-iety: a comprehensive approach. Med Probl Perform Art 1999; 14(3):122-126.

53. Brandfonbrener AG: ß-blockers in the treatment of performance anxi-ety. Med Probl Perform Art 1990; 5(1):23-26.

54. Rosenberg W, Donald A. Evidence based medicine: an approach toclinical problem solving. BMJ 1995; 310:1122-1126.

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