Review

Music Performance Anxiety Part 1. A Review of its Epidemiology

Ariadna Ortiz Brugus, MD, PhD
Music performance anxiety (MPA) affects many individuals regardless of age, gender, experience, and hours of practice. In order to better understand the epidemiology of MPA, a review of the literature was done. Sixteen articles, meeting EBM criteria, were identified and analyzed. Children rarely suffer from MPA, while adolescents show symptoms similar to adults. Females are generally more affected than males. There is no relation between professional experience and performance anxiety. Great musicians such as Pau Casals and Enrico Caruso suffered from MPA. Nevertheless, students affected by MPA may decide not to become professional musicians because of their inability to cope with the devastating effects of performance anxiety. Solo performances showed higher MPA scores than ensemble performances. Despite these conclusions, long-term cohort studies with larger, homogeneous groups of subjects would be desirable, according to the evidence-based medicine criteria. Med Probl Perform Art 2011; 26(2):102105.

lowing the criteria for evidence-based medicine (EBM).22 EBM categorizes different types of clinical evidence and ranks them according to the strength of their freedom from the various biases that affect medical research. Systems to stratify evidence by quality have been developed. According to epidemiologic investigations, in this review the articles are classified as follows:
Level IEvidence obtained from a well-constructed, long-term cohort study Level IIEvidence obtained from a short-term cohort study Level IIIEvidence obtained from a cross-sectional study Level IVOpinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

usic performance anxiety (MPA) is the experience of marked and persistent anxious apprehension related to musical performance that has arisen through specific anxiety-conditioning experiences and which is manifested through combinations of affective, cognitive, somatic, and behavioral symptoms. It affects musicians for their entire lives and is at least partially independent of years of training, practice, and level of musical accomplishment. It may or may not impair the quality of the musical performance.1 Very young children rarely experience performance anxiety; on the contrary, they usually love to perform. Therefore, a transition takes place between childhood and adolescence2 and adulthood for those suffering from MPA. This transition is due to a combination of factors: innate temperament, increasing cognitive capacity and self-reflective function, type of parenting and other interpersonal experiences, perception and interpretation of surroundings, technical skill and mastery, and specific performance experiences that may have positive or negative outcomes. Furthermore, it has been proved that the capacity for self-evaluation (self-criticism) emerges in middle to late adolescence.3 In order to better understand the epidemiology of MPA, a review of the literature was done. Studies were analyzed fol-

Relevant papers were identified by searching Medline and the website archives of Medical Problems of Performing Artists, as well as manual research for specific articles or authors familiar to the author. In addition, the references of these papers were scanned to identify other papers not found by the original search. A total of 16 papers were identified that met the EBM criteria II or III. No papers were identified that met EBM criteria I. Differences in MPA will be shown among age groups, gender, and solo vs ensemble performances. At the end of the each section, conclusions regarding how studies were performed are provided.

CHILDREN MUSICIANS (Table 1)

Simon and Martens4 compared the levels of anxiety among children between 9 and 14 years old under different performance tasks (test, sport, and music). They found that music performance was responsible for the highest levels of anxiety. LeBlanc et al.5 showed that MPA and heart rate increase with audience size and perceived importance of the performance. They also focused on possible gender differences, finding that females presented better performances but reported significantly higher anxiety levels than males. Ryan6 studied a group of 12-year-old piano students, finding that they presented similar physical and physiological symptoms of MPA as adult musicians. Many of them noted a fear of making mistakes in front of people as the primary cause. This study also provided significant correlations

Dr. Brugues obtained her Doktor der Medizin from Albert-Ludwigs-Universitt, Freiburg, Germany. She is currently Medical Doctor at Hospital Universitari Arnau de Vilanova, Lleida, Catalonia, Spain. Address correspondence to Dr. Ariadna Ortiz Brugues, Prat de la Riba, 84 7-4, 25004 Lleida, Spain. Tel +34 626203052. youns84@hotmail.com. 102 Medical Problems of Performing Artists

TABLE 1. Studies of MPA in Children Musicians STUDIES Simon, Martens (1979)4 LeBlanc, et al. (1997)
5

EVALUATION Level II Level II

STUDY DESIGN 749 boys, 914 yrs old, comparing anxiety in test, sport, and musical activities. 27 male and female high school band members performing solos under 3 levels of audience presence: alone in a practice room, in a practice room with one researcher present, and in the rehearsal room with all researchers, a peer group, and a tape recording being made. 26 12-yr-old piano students, comparing heart rates monitored continuously through a piano lesson and a recital performance for each subject. The state portion of the State-Trait Anxiety Inventory for Children (STAI-C) was administered to subjects at the recital. The trait portion of the STAI-C, the Coopersmith Self-Esteem Inventory, and individual interviews were completed during non-performance times before and after the recital. 26 grade-school students under 12 yrs old performing in a piano recital were monitored continuously on measures of heart rate and behavior. They were interviewed in the months prior to the recital and they completed the STAI-C immediately after performing. 173 children, 3-7 yrs old, who completed the trait and state form of the STAI-C during a regular school day and the state form again on the day of a major school concert.

Ryan (1998)6

Level II

Ryan (2004)7

Level II

Ryan (2005)8

Level II

between self-esteem, particularly social self-esteem, and both state anxiety and trait anxiety. The results from heart rate studies agreed with those shown by LeBlanc et al.5 Focusing on gender differences, Ryan7 in a second study found that girls had higher heart rates than boys immediately prior to but not during their performances, while boys had more anxious behaviors than girls both prior to and during a performance. This finding conflicts with LeBlanc et al.s results that females had higher anxiety levels than males. However, the group ages vary between the two studies, so it could be concluded that boys at the age of 12 present more anxious behaviors than their female peers, both prior to and during a performance. High school females, on the contrary, have higher performance anxiety levels than high school males. In a sample of 3- to 7-year-old children, Ryan8 assessed performance anxiety in 173 children, using their answers on the trait and state form of the State-Trait Anxiety Inventory for Children completed during a regular school day and then the state form again on the day of a major school concert. Results showed that state anxiety was significantly higher on the day of the school concert than during a regular school day and that this state anxiety was related to a childs level of trait anx-

iety. This study reveals, surprisingly, the existence of performance anxiety among children, which may share characteristics with its manifestation in adults. The studies presented here were well designed and show very interesting results. The number of subjects evaluated was consistent, and the group ages were clearly defined. None of them was a long-term cohort study, however, and so additional studies would be beneficial, where a well-designed study has large enough samples, clear group age designs, and results showing possible gender differences.

ADOLESCENT MUSICIANS (Table 2)

A survey conducted by Shoup9 among a respectable number of high school music students showed that the proportion of students indicating symptoms of performance anxiety was approximately the same as in professional musicians, with more than 18% of the students admitting these symptoms to be severe enough to have a negative impact on their performance. In a study conducted by Britsch10 among musicians playing in youth orchestras, performance anxiety was also reported frequently, as well as other performance-related prob-

TABLE 2. Studies of MPA in Adolescent Musicians STUDIES Shoup (1995)9 Britsch (2005)10 Fehm, Schmidt (2006)11 Kenny, Osborne (2006)12 Osborne, Kenny (2008)13 EVALUATION Level III Level III Level III Level II Level III STUDY DESIGN 425 high school and junior high school band and orchestra students were surveyed about performance-related problems. 97 students in four youth orchestras in a midsized midwestern city (USA) were surveyed. 74 pupils, age 1519 yrs old, who attended a German special music school. 381 young musicians, age 12 to 19 yrs, attending secondary high schools. Somatic and cognitive features, performance context, and performance evaluation were investigated. 298 music students were asked to provide written descriptions of their worst performance, what happened and how they felt, specifying their age at that time, audience members, and any events that occurred subsequent to the performance. June 2011 103

TABLE 3. Studies of MPA in Orchestra Musicians STUDIES Fishbein, et al. (1988)14 Lockwood (1989)15 van Kemenade, et al. (1995) James (1998)17
16

EVALUATION Level III Level III Level III Level III

STUDY DESIGN National survey of 2,122 professional orchestral musicians at the International Conference of Symphony and Opera Musicians (ICSOM). Survey of 48 US orchestras (ICSOM). 155 of 650 professional musicians playing symphonic orchestras in The Netherlands completed a self-report questionnaire concerning performance anxiety. Survey of 56 orchestras.

lems such as musculoskeletal disorders. A survey by Fehm and Schmidt11 among a group of 15- to 19-year-old music students reported that about one third were handicapped by their performance anxiety, most of them calling for more support from their private teachers to cope with anxiety. Kenny and Osborne12 studied a large group of music students between ages 15 and 19 years and found that MPA was more closely related to social anxiety than trait anxiety. They discovered that the cognitive component of anxiety contributed to the prediction of MPA more than the somatic component. They concluded that the experience of MPA may begin early in a musical career and the characteristics of this experience are qualitatively similar to those experienced by adult musicians. This last statement matches the findings of the study conducted by Ryan6 with children musicians. Osborne and Kenny,13 using written descriptions given by a good sample of music students, concluded that negative cognitions were more predictive of adolescent MPA than the behavioral, somatic, or affective components of the sensitizing experience. They also concluded that music students who reported a negative music performance experience selfreported higher levels of MPA than those who did not report such an experience. MPA was found to be best predicted by trait anxiety and gender, with females reporting more emotional distress than males and having significantly higher total scores. This fact matches with the study by LeBlanc et al.,5 who also found that females (high school music students) had higher anxiety levels than males under performance conditions. Although the results of these studies are promising, most of them are cross-sectional so it would be desirable to have more cohort studies with adolescent musicians of different ages and gender.

ORCHESTRA MUSICIANS (Table 3)

All of the studies here reviewed for orchestra musicians are EBM Category III, so it would be desirable to undertake a long-term cohort trial with a good sample of orchestra musicians. Four studies had an appropriate number of participants, but they were all based solely on surveys and none of them is recent. Both Fishbein et al. (1988)14 and Lockwood (1989)15 studies were based on the survey from the International Conference of Symphony and Opera Musicians (ICSOM), reporting that 24% of respondents suffer from stage fright. The number increased to 58% in the study by van Kemenade et al. (1995)16 and 70% in the one by James (1998).17 This variability can be attributed to differing terms used in each study. Fishbein et al. and Lockwood used the term stage fright, while van Kemenade et al. wrote about performance anxiety, and James quoted having experienced anxiety severe enough to interfere with their performance. Furthermore, there is a difference of 10 years between the first study (Fishbein et al.14) and the last one (James17). It is well known that musicians are typically ashamed of admitting to suffer from performance anxiety. Moreover, in 1988 very few studies focused on therapies as a means to deal with performance anxiety, while in 1998 more studies about the subject had been written. The more that musicians are educated about MPA, the more readily they can recognize its prevalence in other musicians without feeling ashamed. Along with performance anxiety, Fishbein et al.14 reported muscle pain among musicians, lower-back and neck being the most affected parts of the body. Among other psychologic disturbances, depression and acute anxiety were highly reported. Interestingly, van Kemenade et al.16 showed that there was no difference between men and women reporting perform-

TABLE 4. Studies of MPA in Singers STUDIES Sandgren (2002)

18

EVALUATION Level III Level II

STUDY DESIGN 15 opera singers were asked to report problems related to their professional work, coping strategies, motivational factors, and strongly emotional singing experiences. Relationships among state and trait anxiety, occupational stress, perfectionism, aspiration, and MPA were studied in a group of 32 elite operatic chorus artists employed full-time by a national opera company.

Kenny, et al. (2004)19

104

Medical Problems of Performing Artists

TABLE 5. Number of Studies Evaluated by EBM Level Level _____________________________ I II III IV 0 0 0 0 5 1 0 1 0 4 4 1 0 0 0 0

Elements Children musicians Adolescent musicians Orchestra musicians Singers

affect individuals of different ages with different frequency, being rare among children but presenting the highest scores among adolescents between 14 and 19 years old.2 The age at which the desire to perform transforms into MPA symptoms has yet to be investigated. Some of the studies investigated gifted young musicians, while others did not make this difference. It would be very interesting to have studies that compared the results between gifted and non-gifted young musicians.

ance anxiety. Moreover, they found a substantial percentage of musicians who displayed symptoms of anxiety for days, weeks, and even months prior to a performance. This matches the survey taken by James,17 who found 16% of the sample having the same level of anxiety that they experience during a performance more than once a week.

REFERENCES
1. Kenny DT: Music performance anxiety. In Williamon A, ed. International Handbook of Musicians Health and Well- Being. New York: Oxford University Press; 2008. Osborne MS, Kenny DT, Holsomback R: Assessment of music performance anxiety in late childhood. Int J Stress Manage 2005; 12:312330. Jackson B, Lurie S: Adolescent depressionchallenges and opportunities: a review and current recommendations for clinical practice. Adv Pediatr 2006; 53(1):111-163. Simon JA, Martens R: Childrens anxiety in sport and nonsport evaluative activities. J Sport Psychol 1979; 1:160-169. LeBlanc A, Jin YC, Obert M, Siivola C: Effect of audience on music performance anxiety. J Res Music Educ 1997;45:480-496. Ryan C: Exploring music performance anxiety in children. Med Probl Perform Art 1998; 13(3):83-88. Ryan C: Gender differences in childrens experience of music performance anxiety. Psychol Music 2004; 32:89-103. Ryan C: Experience of music performance anxiety in elementary school children. Int J Stress Manage 2005; 12:331-342. Shoup D: Survey of performance-related problems among high school and junior high school musicians. Med Probl Perform Art 1995; 10(3):100-105. Britsch L: Investigating performance-related problems of young musicians. Med Probl Perform Art 2005; 20(1):40-47. Fehm L, Schmidt K: Performance anxiety in gifted adolescent musicians. J Anx Disord 2006; 20(1):98-109. Kenny DT, Osborne MS: Music performance anxietynew insights from young musicians. Adv Cogn Psychol 2006; 2(2-3):103-112. Osborne MS, Kenny DT: The role of sensitizing experiences in music performance anxiety in adolescent musicians. Psychol Music 2008; 36:447-462. Fishbein M, Middlestadt SE, Ottati V, et al: Medical problems among ICSOM musiciansoverview of a national survey. Med Probl Perform Art 1988; 3(1):1-8. Lockwood AH: Medical problems of musicians. N Engl J Med 1989; 320:221-227. van Kemenade JF, van Son MJ, van Heesch NC: Performance anxiety among professional musicians in symphonic orchestrasa self-report study. Psychol Rep 1995; 77:555-562. James I: Western orchestral musicians are highly stressed. Resonance Int Music Council 1998; 26:19-20. Sandgren M: Voice, soma, and psyche. Med Probl Perform Art 2002; 17(1):11-21. Kenny DT, Davis P, Oates J: Music performance anxiety and occupational stress amongst opera chorus artists and their relationship with state and trait anxiety and perfectionism. J Anx Disord 2004; 18:78-82. Wolfe ML: Correlates of adaptative and maladaptative music performance anxiety. Med Probl Perform Art 1989; 4(1):49-56. Miller SR, Chesky K: The multidimensional anxiety theory. Med Probl Perform Art 2004; 19(1):12-20. Rosenberg W, Donald A. Evidence based medicine: an approach to clinical problem solving. BMJ 1995; 310:1122-1126.

2.

SINGERS (Table 4)
Two studies examined MPA in singers. Both studies showed that singers, as well as instrumentalists, suffer from performance anxiety, depression, and other somatic and psychosocial problems, as reported by Sandgren.18 Physical disorders among singers differ from those of other musicians, due to the nature of their instrument (i.e., they primarily use the respiratory tract). In the study from Kenny et al.,19 several scales for performance anxiety which are also used with instrumentalists proved performance anxiety among singers, making a connection between performance anxiety and other elements such as trait anxiety, occupational stress, and perfectionism. Larger samples as well as longer-term cohort studies are desirable.

3.

4. 5. 6. 7. 8. 9.

10. 11. 12.

CONCLUSIONS
13.

As shown in Table 5, there are no gold standard studies. This makes the results less reliable. Well-constructed, long-term cohort studies are required. The number of subjects investigated is often too small and samples are sometimes too specific. Larger samples and from different areas (e.g., from different music schools, although from the same age group) are necessary. During the review of the different studies, it was also noticed that some of them used student and professional musicians within the same sample. As discussed, professional musicians may have lower scores of MPA than students, due to the fact that those students who suffer from MPA are usually deterred from pursuing music as a career since it involves frequent performances.2,20,21 Despite that difference, the intrinsic characteristics of MPA in adolescents are qualitatively similar to those experienced by adult musicians.12 Most of the studies that sampled a group of students did not work with different age groups. As shown, MPA seems to

14.

15. 16.

17. 18. 19.

20. 21. 22.

June 2011

105

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.