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The assessment and treatment of performance anxiety in musicians.

OBJECTIVE: Performance anxiety in musicians may be severe enough to require intervention but has been the subject of relatively little clinical research. The authors' objectives were to describe the results of a comprehensive clinical and laboratory assessment and to perform a double-blind, placebo-controlled study comparing buspirone, cognitive-behavior therapy, and the combination of these treatments for performance anxiety. METHOD: Ninety-four subjects were recruited by mass media announcements and were seen in a university-based outpatient psychiatric clinic. Assessments were 1) questionnaires for all 94 subjects, 2) diagnostic interview of 50 subjects, and 3) laboratory performance of 34 subjects. Treatment conditions were 1) 6 weeks of buspirone, 2) 6 weeks of placebo, 3) a five-session, group cognitive-behavior therapy program with buspirone, or 4) the cognitive-behavior therapy program with placebo. Treatment outcome measures included subjective anxiety ratings and heart rate measures during a laboratory performance, a questionnaire measure of performance confidence, and a blind rating of musical performance quality. RESULTS: All subjects fulfilled criteria for DSM-III-R social phobia. Of the 15 full-time professional musicians, ten had tried propranolol and three had stopped performing. Most of the subjects had substantial anxiety and heart rate increases during laboratory speech and musical performances. Cognitive-behavior therapy resulted in statistically significant reductions in subjective anxiety, improved quality of musical performance, and improved performance confidence. Buspirone was not an effective treatment. CONCLUSIONS: Cognitive-behavior therapy is a viable treatment approach for performance anxiety in musicians.

Adult↗

Development and validation of a music performance anxiety inventory for gifted adolescent musicians.

Music performance anxiety (MPA) is a distressing experience for musicians of all ages, yet the empirical investigation of MPA in adolescents has received little attention to date. No measures specifically targeting MPA in adolescents have been empirically validated. This article presents findings of an initial study into the psychometric properties and validation of the Music Performance Anxiety Inventory for Adolescents (MPAI-A), a new self-report measure of MPA for this group. Data from 381 elite young musicians aged 12-19 years was used to investigate the factor structure, internal reliability, construct and divergent validity of the MPAI-A. Cronbach's alpha for the full measure was .91. Factor analysis identified three factors, which together accounted for 53% of the variance. Construct validity was demonstrated by significant positive relationships with social phobia (measured using the Social Phobia Anxiety Inventory [Beidel, D. C., Turner, S. M., & Morris, T. L. (1995). A new inventory to assess childhood social anxiety and phobia: The Social Phobia and Anxiety Inventory for Children. Psychological Assessment, 7(1), 73-79; Beidel, D. C., Turner, S. M., & Morris, T. L. (1998). Social Phobia and Anxiety Inventory for Children (SPAI-C). North Tonawanda, NY: Multi-Health Systems Inc.]) and trait anxiety (measured using the State Trait Anxiety Inventory [Spielberger, C. D. (1983). State-Trait Anxiety Inventory STAI (Form Y). Palo Alto, CA: Consulting Psychologists Press, Inc.]). The MPAI-A demonstrated convergent validity by a moderate to strong positive correlation with an adult measure of MPA. Discriminant validity was established by a weaker positive relationship with depression, and no relationship with externalizing behavior problems. It is hoped that the MPAI-A, as the first empirically validated measure of adolescent musicians' performance anxiety, will enhance and promote phenomenological and treatment research in this area.

Adolescent↗

Performance anxiety: loss of the spoken edge.

The study aimed to assess whether a specific training program in vocal and physical skills could reduce the level of perceived performance anxiety. Eighteen undergraduate performing arts students were divided into two even groups. The experimental group experienced 10 two-hour sessions in a specialized vocal and physical skills training program. The control group received the same number of sessions in text analysis by the same teacher. Ten weeks after the training period, both groups were videotaped delivering a short speech of general interest. The videotaped material was assessed by four judges, using a visual analog scale (VAS). Perceptual variables considered were eight vocal and physical features: physical ease, physical presence, effective gesture use, effective eye contact, correct breath use, suitable pace, vocal variety, speech clarity, and one performance feature: perceived performance anxiety. Results indicated that the particular vocal and physical skills training program used showed positive results in effectively reducing the level of perceived performance anxiety. The experimental group scored significantly higher on each of the eight vocal and physical features and significantly lower on the perceived anxiety feature than the control group. This research has implications for those affected by performance anxiety in vocal presentation.

Adolescent↗

Treating individuals with debilitating performance anxiety: An introduction.

Clinicians often see clients who have debilitating performance anxiety. They suffer from public speaking anxiety, stage fright, test-taking anxiety, and writing block. Their condition is so severe as to threaten to end their academic or professional career. Musicians and athletes also seek help because their anxiety before and during an event causes them to perform at a level well below their demonstrated capabilities. An estimated 2% of the U.S. population is afflicted by debilitating performance anxiety. Effective treatments are now available. This article reviews those behavioral, cognitive, and technological therapies that have shown great promise for treating individuals who have debilitating performance anxiety and introduces this issue of the Journal of Clinical Psychology: In Session devoted to this topic.

Anxiety Disorders↗

An empirical classification of social anxiety: performance, interpersonal and offensive.

This study empirically identified subtypes of social anxiety using a cluster analytic approach. From 87 out-patients with social phobia (taijin kyofusho) and 48 controls, social anxiety symptoms, social situations in which symptoms occur, and background information were evaluated. Factor analysis using the ratings of social anxiety symptoms identified four factors: socially inadequate feelings, performance anxiety, offensive fear, and tenacity. Four subtypes emerged from cluster analysis based on the factor scores and they were called performance anxiety type, offensive type, interpersonal anxiety type and mild type. Chi2 test and analysis of variance revealed the following: (i) the offensive type had the greatest symptom severity. Any situation could provoke symptoms, and interpersonal tense feelings became much stronger with persons of the same age; (ii) the interpersonal anxiety type was characterized by the fear of social interaction in daily life; and (iii) patients with the offensive type and the interpersonal anxiety type presented more difficulties than did those with the performance anxiety type on developmental and premorbid adjustment.

Adult↗

Music performance anxiety and occupational stress amongst opera chorus artists and their relationship with state and trait anxiety and perfectionism.

This study explored the inter-relationships among state and trait anxiety, occupational stress, perfectionism, aspiration, and music performance anxiety in a group of elite operatic chorus artists employed full-time by a national opera company. The chorus artists reported higher trait anxiety, higher occupational role concerns, and higher occupational personal strain than normative samples. Higher scores on personal resources were associated with the higher scores on trait anxiety. It appears that these resources were used adaptively to manage anxiety. High trait anxiety was also associated with high personal strain in the work environment. Anxiety was not related to occupational roles or issues related to the physical environment or working conditions. These results suggest that while trait anxiety and music performance anxiety were closely associated, occupational stress makes a separate contribution to the quality of working life experienced by elite choral artists.

Adult↗

Performance anxiety in gifted adolescent musicians.

Among professional musicians as well as among music students, performance anxiety occurs frequently and can cause considerable distress. As the professional development starts early among future musicians, younger samples are of great interest, but to date, few studies have examined adolescents. The present survey explored performance anxiety in a sample of 15-19-year-old pupils who attended a German special music school. Of those pupils, 74 participated in the study (93% response rate). In addition to frequency and expression of performance anxiety, coping strategies were assessed. Results pointed to the high frequency of performance anxiety in this sample; about one third of the group were distinctly handicapped by their anxiety. Unfavorable coping strategies, such as drug or alcohol abuse were rarely reported. Most pupils called for more support either from their teachers or from outside of school to cope with their anxiety.

Adaptation, Psychological↗

Stage fright in orchestral musicians: a study of cognitive and behavioural strategies in performance anxiety.

A questionnaire study was carried out with three groups of musicians: experienced professional orchestral players (n=65), music students (n=41), and members of an amateur orchestra (n=40). Musical performance anxiety was assessed together with neuroticism, everyday fears, self-statements and behavioural coping strategies. Performance anxiety was lowest in the professional group and highest among students. In all three groups, performance anxiety was related to neuroticism and everyday fears, notably fear of crowds and social situations. A negative association between age, performing experience and stage fright was observed in professional musicians but not other groups. Six clusters of self-statements were identified. Catastrophizing was positively linked with performance anxiety in all groups, while realistic appraisal of the performance situation was used most commonly by those with moderate levels of stage fright. Implications for the conceptualization and management of stage fright are discussed.

Adaptation, Psychological↗

The occurrence of performance anxiety among musicians.

A questionnaire was given to the students and faculty of the University of Iowa School of Music to learn about their experiences with and attitudes about performance anxiety. Forty-nine (16.5%) of the 302 respondents indicated that their musical performance was impaired by anxiety. Over 21% of the respondents indicated that they experienced marked distress while performing and 16.1% indicated that performance anxiety had adversely affected their careers. Women more frequently reported distress and impairment due to performance anxiety than men. Age was not found to affect problems with performance anxiety. Poor concentration, rapid heart rate, tremor, sweating, and dry mouth were the most commonly reported anxious symptoms. Drug and alcohol use among this group of musicians was minimal. The findings suggest that performance anxiety is an important problem that may in some instances warrant medical treatment.

Adaptation, Psychological↗

Pharmacotherapy for performance anxiety disorders: occasionally useful but typically contraindicated.

Pharmacotherapy is an effective part of treatment for most anxiety disorders, but not for specific phobia or performance anxiety. In them it is contraindicated, because it interferes with the effectiveness of exposure therapies and the extinction of fear responses. Interference with exposure-extinction is a drug side effect that should rarely if ever be tolerated in treating them. This article reviews the many indications for pharmacotherapy in treating most anxiety disorders and contrasts its usefulness in treatment of anxiety disorders with its relatively rare usefulness in treating specific phobias and performance anxiety. In both the latter disorders, benzodiazepines interfere with exposure and generally are best avoided, although temporary use, with safeguards, can sometimes be helpful for a specific phobia. The recent discovery that D-cycloserine (DCS) facilitates exposure and the extinction of anxiety offers promise that it could in the future be usefully and broadly employed to catalyze and enhance exposure therapies.

Antimetabolites↗

Performance anxiety among professional musicians in symphonic orchestras: a self-report study.

155 of 650 professional musicians playing symphonic orchestras in The Netherlands completed a self-report questionnaire concerning performance anxiety. 91 of the 155 respondents reported experiencing or having experienced performance anxiety seriously enough to affect their professional or personal lives. There appeared to be no difference in prevalence between men and women. Substantial percentages of the anxious musicians reported considerable anticipation anxiety days (36%), weeks (10%), or even months (5%) prior to a performance. The results indicate that performance anxiety is a significant professional problem. It is suggested that teaching explicit coping strategies should be incorporated in the curricula of schools of music.

Adaptation, Psychological↗

Development of a rat model of sexual performance anxiety: effect of behavioural and pharmacological hyperadrenergic stimulation on APO-induced erections.

As part of the multifactorial nature of erectile dysfunction, anxiety associated with sexual performance (SPA) remains a major contributing factor to its progression. In fact, the heightened sympathetic activity associated with sexual performance anxiety may be a key early component of this disruption of normal erectile responses. We are not aware that any animal models have been developed to assess this phenomenon. Using apomorphine (APO, 80 microg/kg s.c.)-induced erections in rats we characterised the effects of behavioural or pharmacological hyperadrenergic stimulation (that is, anxiety) on erections and hemodynamics. We developed an experimental SPA paradigm by exposing male rats to the stress of being observed by a larger, older male rat placed in close proximity to test rats during APO testing. In a separate group, adrenergic stress was simulated using a sympathomimetic, methoxamine (MXA) given prior to APO testing. In a third group, the changes in circulatory parameters (mean arterial pressure, heart rate) were determined following instrumentation with radiotelemetric transducers for each scenario. APO-induced erections were significantly lower in both the behavioural (1.25+/-0.8) and pharmacological (0.33+/-0.5) stressor paradigms compared to controls (2.81+/-0.9). Further, erections in MXA-treated rats were significantly lower than in the observed scenario. Despite the differences in erections hemodynamic assessments showed no differences in MAP or HR changes between the different experimental conditions. Thus, both the behavioural and pharmacological paradigms of SPA decreased erections, but did not affect the circulation. This suggests that the level of hyperadrenergic input required to induce erectile dysfunction can be subtle, and target only erectogenic pathways.

Animals↗

Short term dynamic psychotherapy goes to Hollywood: the treatment of performance anxiety in cinema.

This article uses characters in popular films to demonstrate the theory and application of short term dynamic psychotherapy (STDP) in the treatment of performance anxiety. The reader is taught to identify affect phobias that are hypothesized to underlie performance anxiety. Similar in function to external phobias, affect phobias or internal phobias involve the avoidance of feelings (e.g., fear about feeling anger, shame about showing grief, pain about closeness), which thwarts adaptive responding and generates numerous behavioral problems. STDP treatment focuses on the restructuring of defenses, conflicted affects, and attachments. The resolution of the affect phobia requires systematic desensitization of affective responses (i.e., exposure and desensitization of underlying conflicted feelings). When patients learn to access adaptive forms of feelings, performance anxiety can often be resolved.

Affect↗

Performance anxiety during infertility treatment: effect on semen quality.

The requirement to obtain a semen sample at a specific time for an infertility treatment procedure has potential to produce considerable performance anxiety. This study was designed to evaluate the semen quality of men participating in infertility treatments associated with heightened performance anxiety. The most recent pretreatment semen analysis and the infertility treatment semen analysis, as well as the first and last procedure semen analyses, were compared using paired t-tests for 77 patients undergoing assisted reproductive technology procedures and 121 patients undergoing intrauterine insemination. No significant differences were noted in either of these groups of patients. However, in men with total motile sperm counts of less than 40 million, semen parameters improved significantly in the procedure semen analyses. Thus, participation in infertility treatments associated with performance anxiety does not appear to be detrimental to semen quality, and in certain groups of patients semen quality may improve.

Adult↗

Cognitive therapy for performance anxiety.

We present and illustrate the major components of cognitive therapy for performance anxiety, focusing on the performance fears of a client treated with a protocol designed for social phobia. The basic supposition of cognitive theory is that a client's thoughts and beliefs about situations maintain distressing feelings, such as anxiety. Changing these beliefs involves detection and disputation of anxiety-provoking thoughts, as well as testing of these thoughts through exposure to feared situations. Through a process of identifying existing beliefs about performance situations and challenging these beliefs, clients can gain a more realistic and less anxiety-producing perspective on performance tasks. Specific techniques, along with common difficulties and potential solutions, are presented in a detailed case study.

Anxiety Disorders↗

Trading accuracy for speed: gender differences on a Stroop task under mild performance anxiety.

A standard Stroop task was used to examine the effect of performance anxiety on 58 male and 69 female undergraduates. Subjects were approached either by two casually dressed experimenters who did not stress speed or accuracy or by 4 or 5 formally dressed experimenters who stressed quick and accurate performance. Subjects were told the test would assess their "mental acuity"; their responses were visibly tape-recorded. Reaction times did not show differential response by anxiety condition; men and women showed different RTs only in the low-anxiety condition, with women performing significantly more slowly. There were no significant differences for the high-anxiety condition. Analysis of errors showed women were more accurate than men. Men traded accuracy for speed and may have been under equal performance stress in both situations. When performance was not stressed, women were slower and more accurate than men. When performance was stressed, women increased their speed to match that of men while maintaining their greater accuracy.

Adult↗

Effects of intracavernosal pharmacotherapy on self-esteem, performance anxiety and partnership in patients with chronic erectile dysfunction.

156 patients undergoing intracavernosal autoinjection pharmacotherapy for periods of 2-36 months were studied for the effect of treatment on self-esteem, performance anxiety, partnership and acceptance using a semi-structured questionnaire. Replies were received from 86.3% of the patients. 93% gave a very good, good or satisfactory rating of intracavernosal pharmacotherapy. 78.2% indicated that their self-esteem had grown. 79.4% said that performance anxiety diminished in the course of therapy (25.6%) or disappeared entirely (53.8%). 71.8% of the replies confirm the positive effect of treatment on marital relations or partnership. 61.9% of the patients used intracavernosal pharmacotherapy permanently. 28.3% needed therapy intermittently or at large intervals only, and 4.5% (7 patients) were cured of their chronic sexual dysfunction. When preceded by thorough multidisciplinary diagnostics and careful patient selection, intracavernosal pharmacotherapy constitutes an efficient mode of treatment for chronic erectile dysfunction.

Anxiety↗