Music performance anxiety: perceived causes, coping strategies and clinical profiles of Brazilian musicians

Introduction: Music performance anxiety (MPA) is characterized by long-lasting, high intensity apprehension associated with performing music in public. At extreme levels, MPA can impair the career and quality of life. Our goal is to describe the clinical profile, perceived causes and coping strategies associated with MPA. Methods: In this cross-sectional study, several self-assessment instruments were administered to a sample of 214 Brazilian musicians (68% male, 53.3% classical/46.7% popular musicians). Data were analyzed using descriptive and parametric statistics, based on the variables of musical training and level of MPA. Results: Percentages of indicators of pathology were high (40% high MPA levels, 37% social anxiety, 12.5% depression, 13.5% alcohol abuse), and musicians with high MPA levels were the most affected. A wide variety of situations were associated with MPA, especially those related to the individual (pressure from self/ concern about audience). Emotion-focused coping and internal resources were prominent among the resources used for coping with MPA (breathing, increased practice, familiarization with performance venue), although they were not always effective. It was relatively uncommon for musicians to seek specialized resources and treatments. Conclusions: The results demonstrate the vulnerability of the targeted professional groups and the need for preventive strategies and behavioral, environmental, educational, and pharmacological to change this scenario.


Introduction
Music performance anxiety (MPA) is a condition characterized by long-lasting, high intensity apprehension associated with performing music in public. It varies from a state considered common among musicians to extreme levels that are considered pathological. 1,2 Empirical studies indicate that MPA can be understood and classified as a subtype of social anxiety disorder (i.e., MPA shares the same diagnostic criteria as social anxiety disorder, but the fear is restricted to performing in public, which is why the specifier "performance only" is used to classify it). 1,3 As such, it could be treated with relative efficacy. 4 MPA has negative implications for musicians' careers and quality of life, with extreme situations leading to an early exit from the profession. 2 Although the prevalence of MPA has not been precisely established, a literature review 5 reported significant rates ranging from 15% to 25% worldwide.
In Brazil, the prevalence in a sample of professional and amateur musicians was 24%. 2 These substantial rates notwithstanding, MPA has rarely been investigated, recognized and diagnosed.
Many musicians and healthcare providers believe MPA to be inherent to the profession. Consequently, the possibilities for management, treatment and prevention of MPA are restricted, contributing to increased difficulties and suffering for affected individuals. 4 Furthermore, as is widely known, a significant number of musicians selfadminister medications, especially when anticipating a performance, or employ ineffective coping mechanisms, which are often derived from personal strategies. [6][7][8] Such scenarios are a cause for concern and demand attention and action within the public health and musical education fields to develop preventive strategies and implement behavioral, environmental, educational and even pharmacological strategies. The purpose of this study was to describe the clinical profile, perceived causes and strategies for coping with MPA from the perspective of a sample of Brazilian musicians, as a function of their MPA levels and musical training. 4

Methods
The study was approved by the local ethics committee (Process no. 2855/2015).
A convenience sample comprising 214 Brazilian professional musicians was assessed. Participants who had completed undergraduate courses in music and had professional ties to orchestras were categorized as classical musicians. Popular musicians were self-defined as musicians and regularly performed for audiences in various settings (such as bars, religious ceremonies and parties) but did not have academic training in music.

Recruitment was conducted in various states of
Brazil and involved the country's main orchestras and university music schools. The inclusion criteria were as follows: musicians of either sex, over the age of 18, who perform for large audiences at least once a month, and agreed to voluntary participation in the study, as indicated by signature of an informed consent form.
The only exclusion criterion was failure to fill out all of the self-assessment instruments.
The instruments used for data collection are described below.

Kenny Music Performance Anxiety Inventory, revised (KMPAI)
This is a 40-item inventory developed by Kenny 9 to assess anxiety vis-à-vis music performances. It is a revised and expanded version of an earlier 24-item inventory. 10

Anxiety Sensitivity Index
This is a 16-item instrument 12 for identifying the level of anxiety individuals experience in specific situations. It is subdivided into physical (physiological aspects), mental (cognitive aspects) and social (social

aspects) subscales. A version translated into Brazilian
Portuguese was used. 13 The internal consistency of this instrument in that study was 0.88 (Cronbach's alpha).

Causes of Music Performance Anxiety Checklist
This instrument 14

Rating Scale
This is an 18-item self-assessment scale that seeks to identify strategies used by musicians to self-manage MPA. 14  In the present study, the internal consistency of the instrument was α = 0.88.

Patient Health Questionnaire -2 (PHQ-2)
This instrument was designed for screening depressive episodes using two items investigating presence of symptoms over the previous 15 days.
Participants respond to the items on a four-point Likert scale. 18 A version translated into and adapted for Brazilian Portuguese was used and the cutoff point adopted to define presence of depression was 3. 19 The internal consistency of this instrument in the present study was 0.75.

Alcohol Use Disorders Identification Test (AUDIT)
This test was originally developed by the World

Identification Questionnaire
This questionnaire comprises 12 items on the sociodemographic and musical characteristics of the sample.
The instruments were administered individually.
Participants were provided with notebooks containing the instruments described above, accompanied by The significance level was set at 0.05 in all analyses.

Results
The sociodemographic, clinical and musical characteristics of the sample are described in Table 1.
With regard to the data described in Table 1, it is noteworthy that many of the musicians who reported taking medications (n = 39) stated that they did so to treat heart, thyroid and gastrointestinal problems.
Only 4% of the participants (n = 9) reported taking psychotropic agents and 0.9% reported taking beta blockers (n = 2). Table 2 lists results for psychiatric indicators as a function of MPA levels. Considering the cutoff points adopted, approximately 37% of the participants exhibited social anxiety, 40% exhibited high MPA levels, Comparison of the participants as a function of their musical training did not reveal significant differences in material S1 for more information). about audience reaction/evaluation, and presence of trait anxiety. The least frequently perceived causes of MPA were pressure from parents/teachers and a lack of support from close people.
When comparing participants with high and low levels of anxiety, with the exceptions of causes involving inadequate preparation, a lack of support from close people, and pressure from parents/teachers, the group with a high MPA level assessed the situations most frequently associated with anxiety, among which pressure from self and concern about audience reaction/ evaluation stood out. These were also the situations most frequently mentioned as the primary cause of anxiety.
Analysis of the musicians according to their musical training showed that classical musicians mentioned the following as the main causes of MPA: pressure from self, uncertainty attributable to technical flaws, and a difficult repertoire. It should be noted that although pressure from parents and lack of support from close people were not frequently cited by the participants in this group, they were rated as having a high degree of relevance by those participants who did mention them.
Among the popular musicians, there was a trend toward mentioning a broader variety of anxietyinducing situations as cause of MPA, denoting a degree of heterogeneity. Presence of trait anxiety and concern about audience reaction/evaluation were frequently cited and rated at a high degree of relevance. Situations such as lack of support from close people, pressure from parents, inadequate preparation, lack of selfconfidence, health issues, lack of confidence, pressure from teachers and pressure from self were ascribed high values (high degree of relevance), but were seldom mentioned (less frequent) (see supplementary material S2 for more information). Table 4 lists the coping strategies employed by the musicians analyzed and their degree of effectiveness.
Overall, the coping strategies most frequently employed by the whole sample involved use of the individuals' internal/personal resources. The following strategies stood out in terms of frequency and were Musicians with high and low MPA levels used similar coping strategies. Significant differences were only observed for frequency of use of anxiolytics and beta blockers, discussing anxiety with family/friends, and consulting a psychologist, which were more frequently employed by musicians with high MPA levels.
Although there was no difference between classical and popular musicians in terms of the strategies they used most and least frequently, the former more frequently used beta blockers and relaxation techniques, more frequently discussed their anxiety, with their music teachers, and more frequently sought to familiarize themselves with the performance venue. to S6 for more information).

Discussion
This study investigated the clinical profile, perceived causes and coping strategies of MPA among a sample of Brazilian musicians. High percentages of pathological indicators were detected in comparison with the overall Brazilian population, 22 even taking into account the false-negative rates of the screening instruments used.
In a population-based study conducted by Andrade et al., 22 rates of social anxiety, depression, and alcohol abuse were 3.5%, 9.4%, and 2.7%, respectively, whereas the rates identified in the present study were 37.0%, 12.5%, and 13.5%, respectively. These data are alarming and provide evidence of the extreme vulnerability of this population group.
Approximately 40% of the participants exhibited pathological levels of MPA. Although this rate is higher than was detected in a previous study, 2 it is consistent with the higher rates reported in studies performed with samples of Dutch and Japanese musicians (59% and 64%). 23,24 As expected, musicians with high MPA levels also more frequently displayed the other pathological indicators analyzed; a finding that reinforces the association between MPA and psychiatric comorbidities. 2,3 These findings also add weight to the results of previous studies suggesting that MPA is a subtype of social anxiety 3,25,26 that can be predicted by this disorder and shares the same theoretical cognitivebehavioral model. 27,28 However, contrary to expectations, classical musicians (considered to be high performance musicians) did not exhibit higher levels of MPA or other psychopathologies, which contradicts the hypothesis that high demands and long hours of preparation before a performanceboth so common in the lives of orchestra musiciansare risk factors for mental health problems among this population.
However, the classical musicians did exhibit higher rates of anxiety sensitivity with relation to social exposure. Fear of the uncomfortable feelings of anxiety that characterize anxiety sensitivity and a belief that such feelings might have negative social consequences, in addition to the high levels of demands imposed by the musicians themselves and the audience, might be related to this finding. 29 Considering that the musicians' technical flaws, and concern about audience reaction), which might be related to self-esteem issues and perfectionism, which in turn may be more common among musicians with these characteristics. In contrast, problem-focused strategies, which also include seeking healthcare professionals and services (i.e., external resources), were used less often, even though they were perceived to be more effective. The low frequency of seeking medical and psychological care is noteworthy and might reinforce a previous statement in the literature, 2,14 that musicians see MPA as a normal and typical aspect of their profession. This attitude hinders musicians from seeking specialized help, thereby rendering it even more difficult for healthcare professionals to screen for and detect this problem.
The aforementioned considerations evidence the relevance of campaigns to raise awareness of this condition, to explain it, and to publicize the availability of specialized services for the affected population.
Although infrequent, MPA is associated with increased procurement of psychological care. That psychologists are rarely consulted is regrettable, since their therapeutic resources include cognitive-behavioral therapy, which is one of the intervention modalities for treating MPA for which there is the greatest evidence of effectiveness, according to a literature review. 40 The frequency of use of beta blockers was similar to the frequency reported in another Brazilian study that assessed students studying for music degrees (17.3%), 8 but lower than the frequency found in a study conducted with orchestra musicians in Australia (30.9%). 41 This strategy was rated as effective by 80% of the classical musicians and 73.3% of the musicians with high MPA levels who reported using it. The musicians who benefited from beta blockers were possibly those most affected by the physiological symptoms of anxiety because these drugs have no effect on cognitive, emotional, or psychological symptoms. 14 These findings reinforce reports in the literature 6,7,42 on the frequent use of this medication by musicians, especially highperformance musicians, 43 primarily to obtain relief from symptoms such as palpitations, hyperventilation, tremors and nausea. 44 Use of anxiolytics was reported with low frequency, but was rated highly effective. This low frequency of use may be attributable to the undesirable side effects of these drugs, such as impairment of fine motor coordination and performance quality. 8 Although also of low frequency, seeking support from family, friends and teachers was more frequent among both classical musicians and musicians with high MPA levels. It is worth stressing the relevant role of music teachers in the training and guidance of their students, which might be a key element in the process of identifying, understanding and managing MPA. However, as Nascimento 8 observed, more than half of teachers do not provide their students with information about coping strategies, and when they do, their advice is based on common sense rather than on the information available in the literature. Ray et al. 45 analyzed the curricula of various higher education music schools across Brazil and observed that psychological education was scarce in the field of musical training and that little information was provided about psychology as it relates to music performance.
Regardless of their professional training, support from family and friends was highly relevant to the participants in this study. The family and social environments may be perceived as imposing less pressure and fewer demands than the music environment and are more sensitive to suffering. These findings are consistent with Dews & Williams, 46 who reported that friends were named as the primary network of support for music students, whereas formal counseling was rated as the last resource.
One further coping strategy for MPA that merits mention is alcohol consumption. Indeed, in this study, 25% of the participants who reported drinking as a way to cope with MPA exhibited alcohol abuse and rated this strategy as highly effective. This behavior also occurs among individuals with social anxiety, who often drink as a way to cope with anxiety when in situations of exposure. 47 We call attention to the risks associated with alcohol consumption.
Although the strategies most frequently used were ascribed some degree of effectiveness, it is curious that the most effective strategies were not the most frequently used and that some of the least frequently used strategies were rated highly effective. This incongruence calls for serious reflection, especially on the possibility of failure in the management of MPA and the intense suffering experienced by musicians.
These findings reinforce Mejía's 48 observation that musicians employ a wide variety of strategies to cope with MPA intuitively, possibly without guidance from teachers and healthcare providers. To this, one should add the nearly absolute lack of specialized services for the treatment of MPA and other psychopathologies among musicians, particularly in Brazil, and also of initiatives within education and public policy settings for the prevention and promotion of the physical and mental health of musicians.
The main limitation of the present study was the use of self-report scales on signs and symptoms for evaluating psychopathological conditions, especially MPA. Use of structured interviews or clinical diagnosis is suggested for future studies.

Conclusion
The results of this study support the conclusion that there was a high prevalence of MPA among Brazilian musicians, regardless of their field of activity and professional training. A wide variety of situations were associated with occurrence of MPA, among which individual-related situations -particularly pressure from self and concern about audience reactionwere prominent. Emotion-focused coping and internal resources stood out among the resources for coping with MPA, even when they were not always effective.
The respondents seldom reported seeking specialized resources and treatments, which is evidence of the vulnerability of the targeted population group and of the need for action to change this scenario.