Reviews

Music Performance AnxietyPart 2: A Review of Treatment Options

Ariadna Ortiz Brugus, MD, PhD
Music performance anxiety (MPA) affects many individuals independent of age, gender, experience, and hours of practice. In order to prevent MPA from happening or to alleviate it when it occurs, a review of the literature about its prevention and treatment was done. Forty-four articles, meeting evidence-based medicine (EBM) criteria, were identified and analyzed. Performance repertoire should be chosen based on the musicians skill level, and it should be practiced to the point of automaticity. Because of this, the role of music teachers is essential in preventing MPA. Prevention is the most effective method against MPA. Several treatments (psychological as well as pharmacological) have been studied on subjects in order to determine the best treatment for MPA. Cognitive-behavioral therapy (CBT) seems to be the most effective, but further investigation is desired. Some musicians, in addition to CBT, also take blockers; however, these drugs should only be prescribed occasionally after analyzing the situation and considering the contraindications and possible side effects. Despite these conclusions, more randomized studies with larger, homogeneous groups of subjects would be desirable (according to the EBM criteria), as well as support for the necessity of both MPA prevention and optimized methods of treatment when it does occur. Med Probl Perform Art 2011; 26(3):164171.

Catastrophizing has been found to be the best predictor of musical performance anxiety (MPA),3,4 and an association between arm stiffness and MPA has been reported.5 Both facts may contribute to the reason why cognitive-behavioral interventions have proven to have good results in treating MPA, as they focus on changing faulty thinking patterns that give rise to maladaptive behaviors, as well as changing the dysfunctional 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 different treatment options was done, focusing on those that have proven to be more effective: behavioral interventions, cognitive interventions, cognitive-behavioral interventions, combined interventions, others, and drug interventions. At the end of each section, conclusions regarding how the studies were performed are provided. The studies were analyzed using evidence-based medicine (EBM) criteria of Rosenberg and Donald.54 We have used the classification given by Richter, Zander, and Spahn7:
Level I: Systematic review of randomized, double-blind, placebocontrolled trials. A meta-analysis combines the results of several studies that address a set of related research hypotheses. Level II: Evidence obtained from at least one properly designed randomized controlled trial. Level III: Evidence obtained from well-designed controlled trials without randomization. Level IV: Evidence obtained from nonexperimental, nonrandomized trials. Level V: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

ost 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 treatment is to prevent the occurrence of performance anxiety. Awareness of the availability of effective treatments for musicians with performance anxiety should be introduced to student musicians at an early stage of their musical training. Sound pedagogy, appropriate parental support and expectations, and the learning of self-management strategies early in ones musical education can help to mitigate the effects of entering a highly stressful profession. Repeated exposure to the feared situation (music performance) in the absence of the development of skills and strategies to ensure success is likely to have a detrimental effect on the performer with potentially devastating consequences.2 Repertoire should be well within the technical capacity and interpretative abilities of the student, and the material should be over-learned to the point of automaticity.1
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. 164 Medical Problems of Performing Artists

Relevant papers were identified by searching Medline and the website archives of the journal Medical Problems of Performing Artists (www.sciandmed.com/mppa), as well as by 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 44 papers were identified that met the EBM criteria I through V.

INTERVENTIONAL STUDIES
Behavioral Interventions (Table 1) Behavioral therapies focus on changing the dysfunctional behaviors that arise when people feel anxious.6 One of the

TABLE 1. Behavioral Interventions for MPA Studies Appel (1976) Wardle (1969)9 Kendrick et al. (1982)10 Mansberger (1988)11 Grishman (1989)12 Deen (1999)13 Esplen, Hodnett (1999)14 Kim (2005)15
8

Evaluation Level II Level II Level II Level II Level II Level II Level III Level III

Randomization* R R R R R R NR NR

Study Design 30 graduate music students. 30 music students (brass players). 3 (groups) 2 (time) repeated measures design. 53 student pianists with MPA. 3 3 repeated measures design. 19 music students. Simple 2 group comparison. 41 advanced music students and professionals. 2 2 repeated measures design. 39 music students. 2 2 repeated measures design. 21 music students. Guided imagery exercise was used. STAI and LASA (Linear Analog Self-Assessment) scale were used. 6 female college pianists. Effect of a Music Therapy Improvisation and Desensitization Protocol (MTIDP) on alleviating performance anxiety.

*R, randomized; NR, nonrandomized.

main symptoms that occurs is excessive muscle tension, which is treated with deep muscle relaxation training and systematic desensitization. This is a procedure in which the person is encouraged to imagine the anxiety-provoking situation in graded steps, until they can visualize the situation without experiencing the muscle tension. Once the fear hierarchy has been mastered in the therapists office (imaginal desensitization), people are encouraged to apply their new skills in the actual, anxiety-provoking situation (called in vivo desensitization). In all of the studies, behavioral interventions showed a positive effect on reducing performance anxiety, although the kind of intervention often varied from one study to another. Appel8 worked with systematic desensitization, as did Wardle,9 who also introduced insight relaxation. This latter method, interestingly, resulted in greater heart rate reduction than systematic desensitization, although both treatments showed a reduction in anxiety behaviors compared to controls. Kendrick et al.10 worked with students suffering from MPA, creating two groups and utilizing behavior rehearsals in one group and cognitive-behavioral therapy (CBT; based on self-instruction, attention and focusing techniques) in the other. The group treated with behavior rehearsals showed more improvement than controls on the Performance Anxiety Self-Statement Scale, as well as performance quality and visual signs of anxiety, while CBT showed more improvement on Expectations of Personal Efficacy. The positive effects of CBT will be discussed further under the review of CBT interventions. Mansberger11 and Grishman12 worked with muscle relaxation, which proved to positively affect self-efficacy and lower scores on the Self-assessed State Anxiety Scale in the study by Mansberger. Muscle relaxation also had a positive effect on the State-Trait Anxiety Inventory state (STAI-S), symptoms, Music Performance Anxiety Questionnaire (MPAQ), and baseline heart rate in Grishmans report. Deen13 used awareness and breathing exercises, provoking a decrease on the Performance Anxiety Index (PAI). Esplen and Hodnett14 worked with guided imagery exercises, demonstrating a decrease in

anxiety levels, but they found no relationship between those post-intervention anxiety levels and satisfaction with performance. Finally, Kim15 combined rhythmic breathing exercises, free improvisation, and desensitization exercises, reducing performance anxiety. Six of the eight studies analyzed in this category were randomized; only the ones by Esplen and Hodnett14 and by Kim15 were nonrandomized trials. The number of subjects they used also differed; Kim15 studied an extremely small and homogeneous sample (6 female college pianists), and Grishman12 used a sample that was too diverse, with students and professionals in the same treatment group. There also were too many differences in each study measuring performance anxiety in children, adolescent, and adults separately; the same procedure should be performed when applying therapies in order to define more clearly the possible age differences. The number and length of sessions as well as the scales used also varied among the reviewed studies. Behavioral therapies seem to have a positive effect on reducing performance anxiety. However, it would be desirable to perform one randomized study with a large sample that also considered age and possibly instrument differences. Another suggestion is to test different kinds of behavioral interventions separately, while consistently using identical conditions and scales.

GLOSSARY. Assessment Instruments Used in Studies Abbreviation Measure STAI-S LASA MTIDP MPAQ PAI MPASS SE PQ WFPS PRCP State-Trait Anxiety Inventory Scale Linear Analog Self-Assessment Music Therapy Improvisation and Desensitization Protocol Music Performance Anxiety Questionnaire Performance Anxiety Index Music Performance Anxiety Scale Self-efficacy Performance Quality Watkins-Farnum Performance Scale Personal Report of Confidence as a Performer September 2011 165

TABLE 2. Cognitive Interventions for MPA Studies Patson (1996)

16

Evaluation Level II

Randomization* R

Study Design 17 opera students. 3 2 repeated measures design.

*R, randomized; NR, nonrandomized.

Cognitive Interventions (Table 2) Cognitive therapy is more concerned with changing faulty thinking patterns that give rise to maladaptive behaviors.6 In this type of therapy, people learn to replace negative, unproductive, or catastrophic thinking with more rational, useful ways of perceiving their stressful situations. Patson16 found no differences with the use of cognitive therapy. However, his study was only used on singers, and it would be interesting to test cognitive therapy on instrumentalists. A larger sample would also be desirable to detect any changes in the results. A longer treatment period in both singing and instrumentalist groups might also prove effectiveness. Cognitive-Behavioral Interventions (Table 3) CBT is a combination of behavioral and cognitive interventions.6 It helps people identify, analyze, and change counterproductive thoughts and behaviors, thereby alleviating feelings of depression and anxiety. Once these counterproductive patterns are identified, the therapist instructs the patient how to challenge and restructure their behavior and thinking. Behavior is based on rational, reality-based thinking, rather than on negative, catastrophic thinking that impairs a persons capacity to function properly. These studies were mainly based on the use of self-instruction, attention and focusing techniques, although there were differences among them. The three studies were randomized with an acceptable number of participants who were all students suffering from MPA. The study by Kendrick et al.10 has already been analyzed under behavioral interventions. Harris18 added relaxation training, imagery, and behavioral rehearsal to the use of selfinstruction, showing a positive effect on performance anxiety as measured by both PAI and STAI-S scales, as well as rated by teachers. This study also contained a follow-up, which indicated maintained improvements in PAI and teacher rating but interestingly not STAI-S. Roland19 performed two different studies: on the first one he used self-instruction, progressive muscle relaxation, and combination treatment. The results were an improvement on the Music Performance Anxiety Scale (MPASS) for the com-

bined group, maintained on the follow-up, while self-instruction showed pre-post improvement only, and muscle relaxation showed an improvement on performance quality (both on 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. However, when treatment groups were combined, they were superior to controls on STAI, MPASS, Self-Efficacy (SE), but not Performance Quality (PQ), at post-treatment and follow-up. Surprisingly, controls showed lower anticipatory heart rate than both treatment groups. There seems to be a positive effect in the use of CBT for reducing performance anxiety. Nevertheless, it would be interesting to see how these techniques work on professional musicians, as well as differences between age groups. Combined Interventions (Table 4) Six of the seven studies analyzed in this category were randomized (one of the seven was a case report by Lazarus), with an appropriate number of subjects. They differed by using students in some studies and professional musicians in others. The study by Sweeney and Horan20 was performed with students suffering from performance anxiety. Three different groups were made, applying either cue-controlled relaxation, cognitive restructuring, or both techniques combined. Results showed no differences among treatments, with all of them positively affecting performance anxiety. Interestingly, using cue-controlled relaxation and cognitive restructuring separately led to lower pulse rates. Nagel et al.21 also worked with students, while applying a combination of progressive muscle relaxation, cognitive therapy, and biofeedback training. This study showed reduction in performance anxiety. Clark and Agras22 mixed students and professional musicians suffering from social phobia related to performance situations. They formed three treatment groups: CBT plus placebo, CBT plus buspirone, and buspirone alone. The control group was given placebo medication. Results proved CBT to be more effective than buspirone in reducing performance anxiety. Furthermore, placebo groups showed a

TABLE 3. Cognitive-Behavioral Interventions for MPA Studies Kendrick et al (1982) Harris (1987)18 Roland (1993)19
10

Evaluation Level II Level II Level II

Randomization* R R R

Study Design 53 piano students with MPA. 3 2 repeated measures design. 17 students with MPA. 2 3 repeated measures design. 25 student pianists. 3 3 repeated measures design.

*R, randomized; NR, nonrandomized. 166 Medical Problems of Performing Artists

TABLE 4. Combined Interventions for MPA Studies Sweeney, Horan (1982) Nagel et al (1989)21 Clark, Agras (1991)22
20

Evaluation Level II Level II Level II Level II Level II Level II Level IV

Randomization* R R R R R R NR

Study Design 49 music students with MPA. 5 2 repeated measures design. 20 music students with MPA. 2 2 repeated measures design. 29 musicians (including full-time professionals) with social phobia (with regard to performance situations). 4 2 repeated measures design. 18 music students with MPA. 2 2 repeated measures design. 54 professional symphony orchestra musicians. 3 3 repeated measures design. 30 music students. 2 2 repeated measures design. Case report, focusing on a violinist in a symphony orchestra whose career was in serious jeopardy because of extreme fear of performing in public.

Niemann et al (1993)23 Brodsky, Sloboda (1997)24 Sweeney-Burton (1998)25 Lazarus, Abramovitz (2004)26

*R, randomized; NR, nonrandomized.

greater pre- to post-treatment fall in Self-Statement Questionnaire than buspirone groups. Niemann et al.23 used students with MPA, applying biofeedback sessions and group meetings (training in coping strategies, muscle relaxation, breathing awareness, and imagery) as well as coinciding practice of the strategies with sedative music during individual biofeedback training. The treatment showed positive results for reducing anxiety. Brodsky and Sloboda24 worked with professional symphony orchestra musicians, using counseling, counseling plus relaxation and listening to music, and counseling plus relaxation plus music and music-generated vibration sensations as therapies. Few differences between treatments were found, and they showed improvements in anxiety and its symptoms. Sweeney-Burton25 tested the effects of diaphragmatic breathing, progressive muscle relaxation, autogenic training, and biofeedback on students, but results showed no improvement on anxiety. In the case report by Lazarus and Abramovitz,26 the subject responded very well to a focused but elaborate desensitization procedure, consisting of imaginal systematic desensitization, and sessions devoted to his actual performance in the clinical setting. As a homework assignment, the patient found it helpful to listen to a longplaying record of an actual rehearsal and to play along with the world-renowned orchestra and conductor. In summary, combined therapies have proven to decrease performance anxiety, although not all of them have shown equal effectiveness. Once again, it would be desirable to have one study that revealed the differences between students and professionals under exactly the same treatment regimen and during the same period of time. Age group differences, as well as possible variations in the results between singers and instrumentalists, might also be of interest. Considering the lack of success in Sweeney-Burtons studies,25 it would be interesting 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 of certain therapies on reducing performance anxiety. All of the

studies reviewed here were randomized, except the one by Merrit et al.35 McKinney27 studied the effects of biofeedback training on a sample of music students in wind instruments. He found greater a pre- to post-treatment increase in Watkins-Farnum Performance Scale (WFPS), but no changes in either performance anxiety or performance quality as evaluated by three judges. Montello et al.28 tried group music therapy among a sample of musicians with MPA. Results showed a positive effect in reducing MPA and in increasing musicality. Richard29 worked with students experiencing MPA, applying Eriksonian resource retrieval and cue-controlled relaxation. Results proved pre- to post-treatment improvement on the STAI-S and Personal Report of Confidence as a Performer (PRCP) for the Eriksonian group. Stanton30 also worked with students experiencing MPA, but the chosen treatment was hypnotherapy, which proved to have a positive effect in reducing performance anxiety, also in follow-up control. Valentine et al.31 studied the effects of Alexander technique in a group of students. Results showed that the treatment had positive effects in reducing some of the psychical and physiological symptoms of performance anxiety. A metaanalysis study done by Saunders et al.32 indicated that stress inoculation training was an effective means for reducing performance anxiety. Gratto33 proved the effects of an audition anxiety workshop on a sample of students, reporting that it provided a better understanding of what causes audition anxiety and helped students develop techniques to relieve audition stress. Chang34 found no differences in the use of meditation on a group of students compared to the control group. Merrit et al.35 tried a specialized vocal and physical skills training program among undergraduate performing arts students, showing a positive effect on both vocal and physical features, as well as on perceived anxiety. Chang et al.36 found a positive effect of meditation in reducing performance anxiety in a group of students. Furthermore, they reported an increase in relaxation pleasure, even in the period immediately before the performance. Valentine et al.37 tried to reduce stage fright in actors by assigning them either to South Indian techniques or to a neuSeptember 2011 167

TABLE 5. Other Interventions for MPA Studies McKinney (1984) Montello et al (1990)28
27

Evaluation Level II Level II

Randomization* R R

Study Design 32 music students in wind instruments. 2 2 repeated measures design. 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. 21 music students with MPA. 3 2 repeated measures design. 40 music students with MPA. 2 3 repeated measures design. 25 music students. 2 4 repeated measures design. 37 studies with 70 separate hypothesis tests, representing the behavior of 1837 participants. 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 jury examination. 20 music students in piano, violin and voice. Post-test only, control group design. 18 undergraduate performing arts students divided into two even groups. At 10 weeks after the training period, both groups were videotaped delivering a short speech, and the videotaped material was assessed by four judges, using a visual analog scale. 19 students aged 18 to 41 yrs, recruited from the Manhattan School of Music, Mannes College of Music, Yale University School of Music, and SUNY Purchase. 14 actors, with average of 5 yrs professional experience, for whom stage fright was a serious problem, were randomly assigned to a 4-day workshop in either South Indian techniques (Siddha yoga, Kuttiyattam, and the martial arts) or neurolinguistic programming (NLP, specific exercises were directed toward demonstrating that present problems are created by the recollection of past emotions and toward teaching participants how to control getting into high performance states.

Richard (1992)29 Stanton (1994)30 Valentine et al (1995)31 Saunders et al (1996)32 Gratto (1998)33

Level II Level II Level II Level I Level II

R R R R R

Chang (2001)34 Merrit et al (2001)35

Level II Level III

R NR

Chang et al (2003)36

Level II

Valentine et al (2006)37

Level II

*R, randomized; NR, nonrandomized.

rolinguistic program. Both therapies showed beneficial effects in physiological as well as self-report measures. Overall, the results favored the neurolinguistic program as having more potential as a therapeutic technique. In summary, there appears to be a decent number of alternative therapies that seem to reduce performance anxiety. However, there are too few studies performed to fully support the evidence reported by them. Drug Interventions (Table 6) The use of -blockers to treat performance anxiety (referred to as stage fright by most of these authors) has been discussed for many years, and experts often present differing opinions. All of the studies reviewed in this category were nonrandomized. James et al.38 concluded that the use of oxprenolol in musicians improved musical performance overall seen on the first performance and in those subjects most affected by nervousness. Pearson and Simpson39 reported that oxprenolol caused a significant improvement in overall music performance. Neftel et al.40 studied the effects of atenolol on string players. Atenolol showed no significant effect on improving technical-motor performance. It did not influence stage fright
168 Medical Problems of Performing Artists

measured before performing, but reduced it during the concert (measured immediately after the concert). Heart rate was significantly lower under -blockade than under placebo, and urine catecholamine levels increased twice as much under blockade as under placebo before an audience. Brantigan et al.41 measured the effects of propanolol and terbutaline. They concluded that -blockade eliminated the physical symptoms of stage fright (even dry mouth) and improved the quality of musical performance. However, blocker should only be used after consideration of the potentially detrimental effects on musical performance. James et al.42 studied the effects of pindolol on professional musicians. They found a reduction in anxiety associated with an improvement in performance. Stress-related tachycardia and increase in systolic blood pressure were attenuated. James and Savage43 studied the effects of nadolol vs. diazepam in a sample of music students. Nadolol attenuated the rise in heart rate caused by anxiety and improved those elements of string playing that can be adversely affected by tremor. It also improved coordination and judgment. No effect on anxiety was noted for nadolol or for 2 mg diazepam. Diazepam, however, did cause some minor deterioration of performance that was not related to anxiety change.

TABLE 6. Drug Interventions for MPA Studies James et al (1977)

38

Evaluation Level III Level III

Randomization* NR NR

Study Design 24 musicians with stage fright, assessing effect of 40 mg oxprenolol in a double-blind crossover trial. 24 string players from the London colleges and academies of music. Double-blind trial: on the first day, 12 subjects took 40 mg of oxprenolol and 12 took placebo; on the second day, the subjects who had had oxprenolol on the first day received placebo and vice versa. 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. 29 subjects (musicians), assessing effects of propanolol and terbutaline in a double blind study. 30 professional musicians, assessing effect of 5 mg pindolol on stressinduced disturbances of performance. 33 young music students. Effects of 40 mg nadolol vs 2 mg diazepam on performance anxiety of were determined in a double-blind, placebocontrolled, crossover design. 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. Review 150 musicians and singers. Survey of 2,122 orchestral musicians at the International Conference of Symphony and Opera Musicians (ICSOM). 14 healthy males, assessing central effects of single doses of captopril. Two placebos, as well as oxazepam and atenolol, were included. Theory Theory Theory

Pearson, Simpson (1978)39

Neftel et al (1982)40 Brantigan et al (1982)41 James et al (1983)42 James, Savage (1984)43

Level III Level II Level III Level III

NR R NR NR

Gates et al (1985)44

Level III

NR

Lehrer (1987)45 Berens, Ostrosky (1988)46 Lockwood (1989)47 Currie et al (1990)48 Brandfonbrener (1990)49 Lederman (1999)50 Harris (2001)51

Level I Level III Level IV Level III Level IV Level V Level V

NR NR NR

*R, randomized; NR, nonrandomized.

Gates et al.44 reported the effects of different doses of nadolol administered to a group of voice students. Results showed that while the effects of low-dose -blockade were helpful, high doses may detract from performance ability. The study by Lehrer45 was a review which concluded that blockers were less effective for musicians experiencing more cognitive or psychological effects. Berens and Ostrosky46 tested the effects of -blockade in a group of both instrumentalists and singers. They concluded that -blockade decreased tachycardia and improved the quality of the performance, but they also had serious side effects (10% reported bradycardia, hypotension, cold extremities, gastrointestinal upset, sleep disturbance, or muscle fatigue). The survey by Lockwood47 reported that 27% of the orchestral musicians interviewed used propanolol to manage their anxiety prior to a performance, 19% of them using it on a daily basis. Currie et al.48 analyzed the positive and negative effects of captopril, oxazepam, and atenolol on memory and attention tasks. Capropril did not impair performance on any of the tests but improved shortterm memory, without affecting mood or subjective feelings. Oxazeparin reduced subjective alertness, and atenolol increased feelings of sleepiness. Brandfonbrener,49 in an editorial, stated that the use of blockers must be individualized for each subject, and that it should be combined with other psychological therapies. Led-

erman50 supported that -blockers are very effective in counteracting tachycardia, sweating, and tremor, but also advised of the side effects of these drugs. In the report, it is also stated that instrumentalists who require more than occasional medication should probably consider alternative approaches; both medication and nonpharmacologic methods may be used concurrently, if needed. Finally, Harris51 supported that research demonstrates successful alleviation of stage fright in orchestral musicians through the use of blockers, but no comparable data have been collected among dance artists. In summary, it can be concluded that the use of -blockade reduces some of the physiological symptoms of performance anxiety. These drugs should be used only occasionally, and their use along with psychological therapies is highly recommended. However, the use of -blockers is not accepted among many singers and wind instrumentalists, because it has been proven that they increase salivation.52 Doctors should analyze every single patient in order to know if the drug should be prescribed to the subject or not, as well as consider the side effects of -blockade. The recommended dose is 10 to 20 mg of propanolol taken 1 to 2 hrs before a performance53 (or 10 to 40 mg of propanolol taken 60 or 90 min before performance50). It is recommended that musicians take a trial dose a few days before the event, in order to familiarize themselves with the drugs effects and to
September 2011 169

TABLE 7. Number of Studies Evaluated by EBM Level Level ______________________ I II III IV V 0 0 0 0 1 1 2 6 1 3 6 9 1 26 2 0 0 0 1 8 11 0 0 0 1 0 2 3 0 0 0 0 0 2 2

2. 3. 4. 5. 6. 7.

Elements Behavioral interventions Cognitive interventions Cognitive-behavioral interventions Combined interventions Other interventions Drug interventions Totals

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

8. 9. 10.

CONCLUSIONS
As shown in Table 7, almost half of the studies analyzed in this review were non-randomized. This makes the results less reliable. Randomized studies are required. The number of subjects investigated in these reports was often too small, and samples were sometimes too specific. Larger samples and from different areas (e.g., from different music schools, although from the same age group) are necessary. Another field of investigation could be reporting how MPA affects different musicians, depending on what instrument they play. It might be possible that those musicians who play instruments that require more mastery (e.g., violin, piano) would show higher levels of MPA. This hypothesis is based on the fact that MPA varies among subjects, depending on their perception about their capability of succeeding at a performance. As has been shown, one of the first steps for the prevention of MPA is choosing a repertoire that is within the musicians ability. A musician who performs a repertoire that he or she perceives as being extremely demanding will have higher MPA scores. The same procedure could happen among those who play instruments that require more mastery to be played well. Finally, the advantages and disadvantages of medication (propanolol) vs. CBT in terms of time and money can be summed up as follows: the cost of propanolol, although it varies from country to country, is around $0.50 (USD) per pill and should be taken 1 to 2 hrs prior to performing to achieve its effects. The cost of CBT is much higher and varies among specialists, but the average of number of sessions is 4 per week, 2 hours each time, for around 6 weeks. Nevertheless, the advantages of medication are short-lived ones, with possible side effects, whereas CBT has no side effects and the achievement is supposed to last much longer (as it is based on educational and psychological interventions that put the individual in charge of their own change process).

11.

12.

13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.

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