Don’t Call It Stage Fright! New Ideas About Treating Music Performance Anxiety

December 1, 2015

by Patrick Gannon, PhD

Stage fright, or more accurately, music performance anxiety (MPA), is one of the most commonly cited problems for professional musicians.

Surveys show that upwards of half of all musicians, regardless of instrument, genre, and expertise, suffer some degree of MPA. It may be comforting to know that famous sufferers include Frederic Chopin, Maria Callas, Vladimir Horowitz, Arthur Rubenstein, Sergei Rachmaninoff, Carly Simon, Barbra Streisand, George Harrison, Janis Joplin, and even Jimi Hendrix.

How did these expert musicians treat their MPA? Not very well. In fact, standard treatments for performance anxiety—cognitive behavioral therapy (CBT) and relaxation techniques that were borrowed from sport psychology over the last 50 years—have had mixed results when applied to musicians.

For this reason, many performers, such as New York Philharmonic Orchestra violist, Kenneth Mirkin of Local 802 (New York City), have relied on beta-blocker medications such as Inderal. Mirkin, who wrote an essay in Psychology Today about his lifelong struggles with MPA, says he experimented with all types of therapies, but only beta-blockers gave him the symptom relief he needed. While this medication is generally effective at reducing physiological activation of the heart, it does not eliminate the other categories of MPA symptoms—emotional, cognitive, psychological, and behavioral—that can also impair performance.

Recent findings in neuroscience and clinical psychology have given us a better understanding of what causes MPA and how we might improve treatment effectiveness. Neuroscientist Joseph LeDoux’s work at NYU shows that the body’s threat detection system unleashes a barrage of symptoms that go far beyond the simple activation of the sympathetic nervous system. MPA can trigger upwards of 50 symptoms of varying intensity and duration.

The somatic nervous system, the neuroendocrine system, the limbic system and amygdala, as well as the vagus nerve are hardwired to activate a “defensive response” that impacts many aspects of mental functioning essential for playing music. For this reason, treatment needs to target the physiological symptoms first because it appears they drive symptom formation across the other categories. The primacy of the physiological response to threat is why beta-blockers work—and why standard techniques are less effective.

Psychologist Dianna Kenny, who has done extensive research with Australian orchestral musicians, has reconceptualized MPA as a more multifaceted condition. MPA can occur days or weeks prior to performance, aggregate over the long term, and carry forward in an escalating cycle before the musician ever steps on stage. Kenny has identified three sub-types, each emanating from a different biological and/or psychological source that require different treatment plans.

Exposure-based treatments, coupled with “brain-based” techniques, including the time-limited use of beta-blockers, offer the quickest path to symptom reduction. Musicians must learn how to self-regulate their anxiety down to manageable levels, on demand. Mastering this skill, while being exposed to increasingly challenging performance situations, will degrade symptom intensities. While not as simple as taking a pill, this comprehensive treatment strategy offers significant, long-term relief from anxiety—without reliance on beta-blockers.

One overlooked source of MPA is early performance anxiety. Negative performance experiences are often encoded in the brain as trauma. One new “brain-based” treatment is Eye Movement Desensitization & Reprocessing (EMDR). EMDR accesses the implicit memory system in the hippocampus that stores emotional learning, desensitizes traumatic reactions to old performance, and then “installs” new mental scripts that model optimal performance.

The most eagerly awaited treatment for MPA is virtual reality (VR). VR involves using a headset that provides realistic 360-degree visual immersion into a given performance situation. Combining simple CBT and relaxation techniques, while experiencing a virtual performance (without the stress of an audience), desensitizes the psycho-physiological activation that produces the MPA symptoms.

The take-away message is that MPA is treatable—with or without beta-blockers—but you have to have the right plan. Musicians with severe and persistent MPA need to be aggressive in their treatment strategies. One cautionary finding is that, if MPA symptoms are not sufficiently managed, it is difficult to deploy peak performance techniques that can take your performance to the next level. And if MPA is allowed to persist, it may get worse. Like any multisystem mind-body condition, it needs to be adequately treated in order to offer any realistic expectation of sustained relief.

—Patrick Gannon, PhD is a clinical and performance psychologist in San Francisco and a former musician and tennis coach. He is an active member of the Performing Arts Medicine Association (www.artsmed.org). His website is PeakPerformance101.com and his email is drpatrickgannon@ gmail.com. He welcomes questions and comments about this article.