Review

Music performance anxiety (MPA) affects many individuals regard-less of age, gender, experience, and hours of practice. In order tobetter understand the epidemiology of MPA, a review of the litera-ture was done. Sixteen articles, meeting EBM criteria, were identi-fied and analyzed. Children rarely suffer from MPA, while adoles-cents show symptoms similar to adults. Females are generally moreaffected than males. There is no relation between professional expe-rience and performance anxiety. Great musicians such as Pau Casalsand Enrico Caruso suffered from MPA. Nevertheless, studentsaffected by MPA may decide not to become professional musiciansbecause of their inability to cope with the devastating effects of per-formance anxiety. Solo performances showed higher MPA scoresthan ensemble performances. Despite these conclusions, long-termcohort studies with larger, homogeneous groups of subjects wouldbe desirable, according to the evidence-based medicine criteria. MedProbl Perform Art 2011; 26(2):102105.

Music performance anxiety (MPA) is the experience ofmarked and persistent anxious apprehension relatedto musical performance that has arisen through specific anx-iety-conditioning experiences and which is manifestedthrough combinations of affective, cognitive, somatic, andbehavioral symptoms. It affects musicians for their entirelives and is at least partially independent of years of training,practice, and level of musical accomplishment. It may or maynot impair the quality of the musical performance.1

Very young children rarely experience performance anxi-ety; 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 transitionis due to a combination of factors: innate temperament,increasing cognitive capacity and self-reflective function, typeof parenting and other interpersonal experiences, perceptionand interpretation of surroundings, technical skill and mas-tery, and specific performance experiences that may have pos-itive or negative outcomes. Furthermore, it has been provedthat the capacity for self-evaluation (self-criticism) emerges inmiddle to late adolescence.3

In order to better understand the epidemiology of MPA,a review of the literature was done. Studies were analyzed fol-

lowing the criteria for evidence-based medicine (EBM).22

EBM categorizes different types of clinical evidence andranks them according to the strength of their freedom fromthe various biases that affect medical research. Systems tostratify evidence by quality have been developed. Accordingto epidemiologic investigations, in this review the articles areclassified as follows:

Level IEvidence obtained from a well-constructed, long-termcohort 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

Relevant papers were identified by searching Medline andthe website archives of Medical Problems of Performing Artists, aswell as manual research for specific articles or authors famil-iar to the author. In addition, the references of these paperswere scanned to identify other papers not found by the orig-inal search. A total of 16 papers were identified that met theEBM criteria II or III. No papers were identified that metEBM criteria I. Differences in MPA will be shown among age groups,

gender, and solo vs ensemble performances. At the end ofthe each section, conclusions regarding how studies were per-formed are provided.

CHILDREN MUSICIANS (Table 1)

Simon and Martens4 compared the levels of anxiety amongchildren between 9 and 14 years old under different per-formance tasks (test, sport, and music). They found thatmusic performance was responsible for the highest levels ofanxiety. LeBlanc et al.5 showed that MPA and heart rateincrease with audience size and perceived importance ofthe performance. They also focused on possible gender dif-ferences, finding that females presented better perform-ances but reported significantly higher anxiety levels thanmales. Ryan6 studied a group of 12-year-old piano students, find-

ing that they presented similar physical and physiologicalsymptoms of MPA as adult musicians. Many of them noted afear of making mistakes in front of people as the primarycause. This study also provided significant correlations

102 Medical Problems of Performing Artists

Music Performance AnxietyPart 1. A Review of its Epidemiology

Ariadna Ortiz Brugus, MD, PhD

Dr. Brugues obtained her Doktor der Medizin from Albert-Ludwigs-Univer-sitt, 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, 847-4, 25004 Lleida, Spain. Tel +34 626203052. youns84@hotmail.com.

between self-esteem, particularly social self-esteem, and bothstate anxiety and trait anxiety. The results from heart ratestudies agreed with those shown by LeBlanc et al.5

Focusing on gender differences, Ryan7 in a second studyfound that girls had higher heart rates than boys immediatelyprior to but not during their performances, while boys hadmore anxious behaviors than girls both prior to and during aperformance. This finding conflicts with LeBlanc et al.sresults that females had higher anxiety levels than males. How-ever, the group ages vary between the two studies, so it couldbe concluded that boys at the age of 12 present more anxiousbehaviors than their female peers, both prior to and during aperformance. High school females, on the contrary, havehigher performance anxiety levels than high school males. In a sample of 3- to 7-year-old children, Ryan8 assessed per-

formance anxiety in 173 children, using their answers on thetrait and state form of the State-Trait Anxiety Inventory forChildren completed during a regular school day and then thestate form again on the day of a major school concert. Resultsshowed that state anxiety was significantly higher on the dayof the school concert than during a regular school day andthat this state anxiety was related to a childs level of trait anx-

iety. This study reveals, surprisingly, the existence of per-formance anxiety among children, which may share charac-teristics with its manifestation in adults. The studies presented here were well designed and show

very interesting results. The number of subjects evaluated wasconsistent, and the group ages were clearly defined. None ofthem was a long-term cohort study, however, and so addi-tional studies would be beneficial, where a well-designedstudy has large enough samples, clear group age designs, andresults showing possible gender differences.

ADOLESCENT MUSICIANS (Table 2)

A survey conducted by Shoup9 among a respectable numberof high school music students showed that the proportion ofstudents indicating symptoms of performance anxiety wasapproximately the same as in professional musicians, withmore than 18% of the students admitting these symptoms tobe severe enough to have a negative impact on their perform-ance. In a study conducted by Britsch10 among musicians play-ing in youth orchestras, performance anxiety was alsoreported frequently, as well as other performance-related prob-

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TABLE 1. Studies of MPA in Children Musicians

STUDIES EVALUATION STUDY DESIGN

Simon, Martens (1979)4 Level II 749 boys, 914 yrs old, comparing anxiety in test, sport, and musical activities.

LeBlanc, et al. (1997)5 Level II 27 male and female high school band members performing solos under 3 levels of audiencepresence: alone in a practice room, in a practice room with one researcher present, and inthe rehearsal room with all researchers, a peer group, and a tape recording being made.

Ryan (1998)6 Level II 26 12-yr-old piano students, comparing heart rates monitored continuously through a pianolesson and a recital performance for each subject. The state portion of the State-Trait Anxi-ety Inventory for Children (STAI-C) was administered to subjects at the recital. The traitportion of the STAI-C, the Coopersmith Self-Esteem Inventory, and individual interviewswere completed during non-performance times before and after the recital.

Ryan (2004)7 Level II 26 grade-school students under 12 yrs old performing in a piano recital were monitoredcontinuously on measures of heart rate and behavior. They were interviewed in the monthsprior to the recital and they completed the STAI-C immediately after performing.

Ryan (2005)8 Level II 173 children, 3-7 yrs old, who completed the trait and state form of the STAI-C during aregular school day and the state form again on the day of a major school concert.

TABLE 2. Studies of MPA in Adolescent Musicians

STUDIES EVALUATION STUDY DESIGN

Shoup (1995)9 Level III 425 high school and junior high school band and orchestra students were surveyed aboutperformance-related problems.

Britsch (2005)10 Level III 97 students in four youth orchestras in a midsized midwestern city (USA) were surveyed.

Fehm, Schmidt (2006)11 Level III 74 pupils, age 1519 yrs old, who attended a German special music school.

Kenny, Osborne (2006)12 Level II 381 young musicians, age 12 to 19 yrs, attending secondary high schools. Somatic andcognitive features, performance context, and performance evaluation were investigated.

Osborne, Kenny (2008)13 Level III 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.

lems such as musculoskeletal disorders. A survey by Fehm andSchmidt11 among a group of 15- to 19-year-old music studentsreported that about one third were handicapped by their per-formance anxiety, most of them calling for more support fromtheir private teachers to cope with anxiety. Kenny and Osborne12 studied a large group of music stu-

dents between ages 15 and 19 years and found that MPAwas more closely related to social anxiety than trait anxiety.They discovered that the cognitive component of anxietycontributed to the prediction of MPA more than thesomatic component. They concluded that the experience ofMPA may begin early in a musical career and the character-istics of this experience are qualitatively similar to thoseexperienced by adult musicians. This last statementmatches the findings of the study conducted by Ryan6 withchildren musicians. Osborne and Kenny,13 using written descriptions given by

a good sample of music students, concluded that negativecognitions were more predictive of adolescent MPA than thebehavioral, somatic, or affective components of the sensitiz-ing experience. They also concluded that music students whoreported a negative music performance experience self-reported higher levels of MPA than those who did not reportsuch an experience. MPA was found to be best predicted bytrait anxiety and gender, with females reporting more emo-tional distress than males and having significantly highertotal scores. This fact matches with the study by LeBlanc etal.,5 who also found that females (high school music stu-dents) had higher anxiety levels than males under perform-ance conditions.Although the results of these studies are promising, most

of them are cross-sectional so it would be desirable to havemore cohort studies with adolescent musicians of differentages and gender.

ORCHESTRA MUSICIANS (Table 3)

All of the studies here reviewed for orchestra musicians areEBM Category III, so it would be desirable to undertake along-term cohort trial with a good sample of orchestra musi-cians. Four studies had an appropriate number of partici-pants, but they were all based solely on surveys and none ofthem is recent. Both Fishbein et al. (1988)14 and Lockwood (1989)15 stud-

ies were based on the survey from the International Confer-ence of Symphony and Opera Musicians (ICSOM), reportingthat 24% of respondents suffer from stage fright. Thenumber increased to 58% in the study by van Kemenade etal. (1995)16 and 70% in the one by James (1998).17 This vari-ability can be attributed to differing terms used in each study.Fishbein et al. and Lockwood used the term stage fright, whilevan Kemenade et al. wrote about performance anxiety, andJames quoted having experienced anxiety severe enough to inter-fere with their performance. Furthermore, there is a differenceof 10 years between the first study (Fishbein et al.14) and thelast one (James17). It is well known that musicians are typically ashamed of

admitting to suffer from performance anxiety. Moreover, in1988 very few studies focused on therapies as a means to dealwith performance anxiety, while in 1998 more studies aboutthe subject had been written. The more that musicians areeducated about MPA, the more readily they can recognize itsprevalence in other musicians without feeling ashamed. Along with performance anxiety, Fishbein et al.14 reported

muscle pain among musicians, lower-back and neck being themost affected parts of the body. Among other psychologic dis-turbances, 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-

104 Medical Problems of Performing Artists

TABLE 3. Studies of MPA in Orchestra Musicians

STUDIES EVALUATION STUDY DESIGN

Fishbein, et al. (1988)14 Level III National survey of 2,122 professional orchestral musicians at the International Conference of Symphony and Opera Musicians (ICSOM).

Lockwood (1989)15 Level III Survey of 48 US orchestras (ICSOM).

van Kemenade, et al. (1995)16 Level III 155 of 650 professional musicians playing symphonic orchestras in The Netherlandscompleted a self-report questionnaire concerning performance anxiety.

James (1998)17 Level III Survey of 56 orchestras.

TABLE 4. Studies of MPA in Singers

STUDIES EVALUATION STUDY DESIGN

Sandgren (2002)18 Level III 15 opera singers were asked to report problems related to their professional work, copingstrategies, motivational factors, and strongly emotional singing experiences.

Kenny, et al. (2004)19 Level II 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 bya national opera company.

ance anxiety. Moreover, they found a substantial percentageof musicians who displayed symptoms of anxiety for days,weeks, and even months prior to a performance. Thismatches the survey taken by James,17 who found 16% of thesample having the same level of anxiety that they experienceduring a performance more than once a week.

SINGERS (Table 4)

Two studies examined MPA in singers. Both studies showedthat singers, as well as instrumentalists, suffer from perform-ance anxiety, depression, and other somatic and psychosocialproblems, as reported by Sandgren.18 Physical disordersamong singers differ from those of other musicians, due tothe nature of their instrument (i.e., they primarily use the res-piratory tract). In the study from Kenny et al.,19 several scalesfor performance anxiety which are also used with instrumen-talists proved performance anxiety among singers, making aconnection between performance anxiety and other elementssuch as trait anxiety, occupational stress, and perfectionism.Larger samples as well as longer-term cohort studies are desir-able.

CONCLUSIONS

As shown in Table 5, there are no gold standard studies. Thismakes the results less reliable. Well-constructed, long-termcohort studies are required. The number of subjects investigated is often too small and

samples are sometimes too specific. Larger samples and fromdifferent areas (e.g., from different music schools, althoughfrom the same age group) are necessary. During the review of the different studies, it was also

noticed that some of them used student and professionalmusicians within the same sample. As discussed, professionalmusicians may have lower scores of MPA than students, dueto the fact that those students who suffer from MPA are usu-ally deterred from pursuing music as a career since it involvesfrequent performances.2,20,21 Despite that difference, theintrinsic characteristics of MPA in adolescents are qualita-tively similar to those experienced by adult musicians.12

Most of the studies that sampled a group of students didnot work with different age groups. As shown, MPA seems to

affect individuals of different ages with different frequency,being rare among children but presenting the highest scoresamong adolescents between 14 and 19 years old.2 The age atwhich the desire to perform transforms into MPA symptomshas yet to be investigated. Some of the studies investigated gifted young musicians,

while others did not make this difference. It would be veryinteresting to have studies that compared the results betweengifted and non-gifted young musicians.

REFERENCES

1. Kenny DT: Music performance anxiety. In Williamon A, ed. Interna-tional Handbook of Musicians Health and Well- Being. New York:Oxford University Press; 2008.

2. Osborne MS, Kenny DT, Holsomback R: Assessment of music per-formance anxiety in late childhood. Int J Stress Manage 2005; 12:312-330.

3. Jackson B, Lurie S: Adolescent depressionchallenges and opportuni-ties: a review and current recommendations for clinical practice. AdvPediatr 2006; 53(1):111-163.

4. Simon JA, Martens R: Childrens anxiety in sport and nonsport eval-uative activities. J Sport Psychol 1979; 1:160-169.

5. LeBlanc A, Jin YC, Obert M, Siivola C: Effect of audience on musicperformance anxiety. J Res Music Educ 1997;45:480-496.

6. Ryan C: Exploring music performance anxiety in children. Med ProblPerform Art 1998; 13(3):83-88.

7. Ryan C: Gender differences in childrens experience of music per-formance anxiety. Psychol Music 2004; 32:89-103.

8. Ryan C: Experience of music performance anxiety in elementaryschool children. Int J Stress Manage 2005; 12:331-342.

9. Shoup D: Survey of performance-related problems among high schooland junior high school musicians. Med Probl Perform Art 1995;10(3):100-105.

10. Britsch L: Investigating performance-related problems of young musi-cians. Med Probl Perform Art 2005; 20(1):40-47.

11. Fehm L, Schmidt K: Performance anxiety in gifted adolescent musi-cians. J Anx Disord 2006; 20(1):98-109.

12. Kenny DT, Osborne MS: Music performance anxietynew insightsfrom young musicians. Adv Cogn Psychol 2006; 2(2-3):103-112.

13. Osborne MS, Kenny DT: The role of sensitizing experiences in musicperformance anxiety in adolescent musicians. Psychol Music 2008;36:447-462.

14. Fishbein M, Middlestadt SE, Ottati V, et al: Medical problems amongICSOM musiciansoverview of a national survey. Med Probl PerformArt 1988; 3(1):1-8.

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

16. van Kemenade JF, van Son MJ, van Heesch NC: Performance anxietyamong professional musicians in symphonic orchestrasa self-reportstudy. Psychol Rep 1995; 77:555-562.

17. James I: Western orchestral musicians are highly stressed. ResonanceInt Music Council 1998; 26:19-20.

18. Sandgren M: Voice, soma, and psyche. Med Probl Perform Art 2002;17(1):11-21.

19. Kenny DT, Davis P, Oates J: Music performance anxiety and occupa-tional stress amongst opera chorus artists and their relationship withstate and trait anxiety and perfectionism. J Anx Disord 2004; 18:78-82.

20. Wolfe ML: Correlates of adaptative and maladaptative music perform-ance anxiety. Med Probl Perform Art 1989; 4(1):49-56.

21. Miller SR, Chesky K: The multidimensional anxiety theory. Med ProblPerform Art 2004; 19(1):12-20.

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

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TABLE 5. Number of Studies Evaluated by EBM Level

Level_____________________________Elements I II III IV

Children musicians 0 5 0 0Adolescent musicians 0 1 4 0Orchestra musicians 0 0 4 0Singers 0 1 1 0

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