Definition, prevalence and treatment of MPA: current state of research
Music performance anxiety (MPA) can be defined as a subentity (“performance only” subtype) of social anxiety according to DSM-5 (F40.10) or as specific phobia as coded by the ICD-10 (F40.2)[
1]. Although a common definition of the disorder ist still missing, it has to be differentiated from normal stage fright [
1,
2]. According to the definition by Dianne Kenny, one of the leading researchers in the field of MPA, MPA is a “
combination of affective, cognitive, somatic and behavioural symptoms which may occur in a range of performance settings, but is usually more severe in settings involving high ego investment and evaluative threat” [
3, p. 433]. Whereas stage fright is a common and normal phenomenon among professional musicians, usually considered positive and performance-enhancing, MPA is considered a pathological fear that significantly affects the musical and artistic performance of the individual and therefore causes psychological distress and/or impaired functioning. In individual cases, severe MPA can even lead to the termination of the professional career. Since the transition from stage fright to MPA is smooth, the discrimination of both concepts is not always easy [
2]. Mumm et al. draw an analogy to the
Yerkes-Dodson curve to describe the dependence of arousal level on performance quality. An optimal condition of the arousal enables an optimal performance quality which is in the form of a U-shaped curve. An arousal level that is too high, as occurs with MPA, has a correspondingly negative effect on performance quality [
2] (Fig.
1). Fernholz at al. [
1] state MPA as the most frequently reported (anxiety) disorder among professional musicians. The prevalence of MPA varies in studies between 17% and 59% [
1,
2] which can be attributed to the heterogeneity of sample size, methodology and definitions of MPA in these studies. Considering a minimum standard of criteria-based and standardized diagnostic, a prevalence of 15–25% can be assumed of which again only a small percentage of approximately 15% seems to seek professional help [
1,
2,
4]. In a recent study based on questionnaires of 532 musicians Spahn et al. characterize three different types of MPA depending on symptoms, functional coping and performance-related self-efficacy [
5]. Typical symptoms of performance-reducing MPA include subjectively experienced fear of failure or loss of control and on a physical level the consequences of an increase in sympathetic activity with cardiac stress. These include an increase in heart rate (tachycardia), blood pressure as well as an increased respiratory rate, tremor, nausea and flush reactions in the face. With regard to control of breathing, attachment, voice, and hand functions, these symptoms can seriously impact the sensorimotor performance, but also the flow state of musicians during music performance [
6].
Cardiac stress with tachycardias and a mean heart rate of 130–160 bpm are very common in solo performances by instrumentalists [
7,
8]. This aligns with observations in high-performance athletes, which are known to have a higher risk to experience cardiac arrhythmias [
9‐
11]. In extreme cases, musicians of different musical genres may even suffer an acute cardiovascular event during a performance, such as a heart attack (Mariss Jansons 1996 (1943–2019)) or cerebral hemorrhage (Simon Barere, 1896–1951; Giuseppe Sinopoli, 1946–2001). Due to the concomitant sympathetic activation, musicians with MPA often resort to beta-blockers, although the reduction in physical signs and symptoms does not guarantee the reduction of psycho-emotional and cognitive factors (e.g. dysfunctional thoughts and misgivings) [
3]. In general, serious mental illnesses are associated with high cardiovascular disease risk [
12]. Although cardiovascular symptoms have been investigated in MPA [
7,
13,
14], there is no study so far that investigated the therapeutic effects on sympathetic activity and cardiovascular reactivity for musicians with MPA. Guyon et al. rightly point out that studies about the “psychobiological and performance-related concomitants of MPA are limited” [
15]. Their recent study is based on a promising approach of the biopsychosocial model of challenge and threat and investigates changes in psychobiological responses in MPA – data which is long overdue in the field of MPA.
Furthermore, no studies have been performed on blood-based therapy-related biomarkers in MPA. However, blood is currently the medium that is available for diagnostic purposes with little expenditure of time and personnel, as well as not being burdensome for the patient. Some first evidence of the potential utility of such blood-based biomarkers for the prediction of exposure therapy response comes from metabolomic and epigenetic studies in patients with Panic Disorder [
16‐
18].
With regard to therapy of MPA, there exist manifold coping strategies and therapeutic interventions in the field of evidence based medicine such as cognitive behavioral therapy (CBT), medication with beta blockers but also complementary therapy methods like music therapy or Alexander technique described in detail by Fernholz et al. [
1]. Early studies with behavioral interventions have been done since the 1990s. One of these initial studies by Clark & Agras [
19] examined 94 musicians in a double-blind, randomized, placebo-controlled study. The anxiolytic buspirone was compared with CBT and a combination of both, in which the group with cognitive-behavioral intervention (n = 15) showed a significantly better treatment result compared to the group without cognitive-behavioral intervention (n = 14). Overall, behavioral therapy was already considered as “useful” at that time [
19]. A non-randomized intervention study with 26 musicians from 2005 showed a positive effect on heart rate and superiority of situation-dependent use of propranolol compared to progressive muscle relaxation (PMR), but with a clear improvement in psychological well-being through PMR before and after a musical performance [
7]. Overall, the study situation on the use of relaxation techniques such as PMR for the therapy of MPA is currently extremely limited (e.g. music-assisted PMR in pianists [
20]). Moreover, there exist some recent studies investigating different approaches on therapy and coping strategies of MPA using acceptance and commitment therapy but also expressive writing [
21‐
25]. Some studies have an explorative character with a single-subject design [
22].
Considering all of the above, this study aims to close the existing gap by investigating therapeutic effects of cognitive-behavioral exposure therapy using virtual reality compared to a relaxation training. Besides psychological measures, physiological measures such as parameters for sympathetic activity measurable in the peripheral blood and cardiovascular reactivity will be considered as therapeutic outcomes.
With regard to benefits and harms, in the best case, the therapeutic interventions lead to an immediate and short-term reduction of music performance anxiety and could also provide an individual coping tool to increase self-efficacy in performance situations. Direct harms of the therapies are not to be expected. Of course, VR exposure may lead to experiencing anxiety and therefore to an increase in heart rate and blood pressure. For this reason, participants with a history of heart disease are not included in the study. Furthermore, the VR could lead to a simulation sickness in form of transient dizziness. In the case of PMR, there may be short-term muscle pain in some parts of the body. If complaints or disorders of the cervical spine are known ahead to the PMR intervention, the cervical muscle group is being omitted. Overall, these potential benefits could help promote participant retention and to motivate participants to complete follow-up.
The application of virtual reality in psychiatry and psychotherapy and MPA
According to the German S3 guidelines for anxiety disorders, the therapy recommendation with the highest level of evidence is CBT, which includes exposure accompanied by a therapist [
26]. Exposure therapy can be carried out in vivo and in a virtual reality (VR) setting [
26]. Despite established therapy methods, only about a third of those affected receive therapy specifically designed for anxiety disorder (e.g. social phobia patients [
27]).
In the case of virtual reality exposure therapy (VRET), the exposure takes place in a virtual space, which the subject can explore using special VR glasses. This type of exposure for anxiety disorders has already been tested in several large, controlled, randomized studies (for review in social anxiety disorders see [
28]). It has been shown that VRET can not only trigger specific anxiety symptoms in patients with social phobia [
29], but also reduce them just as effectively in the VR setting as exposure in vivo [
30,
31]. VRET offers several advantages for both the therapist and the patient. The intensity of the feared situation can be tailored to the patient and the exposure session can be carried out directly in the treatment room [
30]. This is especially the case for musicians, since a fear-triggering musical performance setting (with a jury or audience) is not always available and even more impeded in pandemic times. Furthermore, the threshold for seeking psychological help can also be lowered by using VRET [
30].
In a case study in 2004, Orman first integrated a behavioral exposure approach with VR for music anxiety [
32]. Some additional therapy studies [
32‐
36] are using a VRET on MPA, although only small samples (n = 1–17) were examined. These five exploratory studies investigated the application of VR by musicians. In three studies, VR was used in terms of
exposure training [
32,
34,
35] and in two studies in terms of
simulation training [
33,
36]. However, musicians suffering from MPA in terms of a psychiatric disorder were not included. With regard to a psychometric assessments of anxiety only two studies used questionnaires such as the STAI-S and STAI-T [
34]. In summary, Matei & Ginsborg [
37] criticize the methodological weaknesses of many studies with too short study periods, small sample sizes, and a lack of controls. Although, larger and randomized clinical trials are still missing, all of these studies highlight the benefits of VR with far-reaching implications in simulation and performance training of musicians and call for further studies. In addition, Burin et al. [
38] emphasize a “great need for preventive strategies and behavioral, educational, and pharmacological interventions”.
Study aims and hypotheses
The study aims to evaluate the effectiveness of VRET for the treatment of MPA compared to an active control group receiving Jacobson’s PMR. The study sample comprises professional and semi-professional musicians and music students. The primary outcomes are change of MPA and heart rate variability. In addition, changes in stress parameters such as the cortisol response as well as immunological parameters, neuropeptides and epigenetic markers before and after a musical performance situation in VR will be examined.
The study addresses the following main questions: How effective is exposure therapy for MPA assessed by the reduction of subjective anxiety symptoms and objective cardiovascular parameters? We hypothesize that VRET will exert a significant and lasting reduction of subjective MPA symptoms at T1 (post/ approximately one week after the treatment) and at T2 (follow up/ six months after the treatment) compared to T0 (pre/ before the treatment). Also, we expect this reduction of MPA symptoms, at T1 and T2 compared to T0, to be significantly stronger for the experimental group receiving the exposure training compared to the control group receiving PMR. We further hypothesize that the postulated reduction of MPA in the experimental group goes along with a significantly higher HRV representing less cardiac stress during the musical performance situation in VR at T1 and T2 compared to T0. To conclude, the focus is primarily on the effectiveness of VRET compared to PMR.