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A SURVEY OF MUSIC PERFORMANCE ANXIETY:
DEFINITIONS, CAUSES AND TREATMENTS
by
Lacey Hutchison Marye
Bachelor of Arts
University of Central Oklahoma, 1997
Master of Arts
Oklahoma State University, 2003
________________________________________________
Submitted in Partial Fulfillment of the Requirements
For the Degree of Doctor of Musical Arts in
Piano Pedagogy
School of Music
University of South Carolina
2011
Accepted by:
Dr. Scott Price, Major Professor
Dr. Charles Fugo, Committee Member
Dr. Marina Lomazov, Committee Member
Dr. Zachary Kelehear, Committee Member
Dr. Timothy Mousseau, Dean of The Graduate School
UMI Number: 3454396
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ii
DEDICATION
To my supportive parents, Ken and Lynda Hutchison, and loving husband, Robert Marye;
I could not have completed this dissertation without you.
iii
ACKNOWLEDGEMENTS
It is with grateful appreciation that I acknowledge the significant contribution of
my academic advisor and director of this dissertation, Dr. Scott Price. His foresight,
invaluable scholarly knowledge, editorial counsel, and encouragement throughout the
journey of writing this document were monumental to the researcher’s success as a
musician and pedagogue.
Appreciation is given to my piano professor and mentor, Dr. Marina Lomazov,
whose support, guidance and inspiration were vital to the researcher’s development as a
musician and pedagogue.
My sincere thanks are given to Dr. Charles Fugo, Dr. Zach Kelehear, and Dr.
Samuel Douglas for serving on my committees throughout my doctoral studies.
Grateful appreciation is given to licensed professional counselor and psychiatric
RN Rachel Maw for providing the researcher with psychological resources.
I extend my deepest gratitude to my family Robert Marye, Ken and Lynda
Hutchison, Angie Parent, Braden Marye and Brett Marye. Thank you for listening to my
discoveries and cheering me on throughout the research and writing of this dissertation.
Your unconditional love, continued support, and encouragement have been a strong
support system for me throughout my graduate studies.
iv
ABSTRACT
The purpose of this document was to provide a basic guide for piano instructors
and performers about the undesirable experience of performance anxiety. The study
surveyed the history, current thought, definition, diagnosis, and causes and effects of
performance anxiety. Current treatments and therapies for performance anxiety, such as
systematic desensitization, relaxation techniques, prescription drugs and alternative or
homeopathic aids are examined. The final chapter consists of a conclusion, bibliography,
and appendices of treatment facilities.
v
PREFACE
This treatise is part of the dissertation requirement for the
Doctor of Musical Arts degree in Piano Pedagogy.
vi
TABLE OF CONTENTS
DEDICATION ………………………………………………………………………….. iii
ACKNOWLEDGEMENTS …………………………………………………..………… iv
ABSTRACT ……………………………………………………………………………... v
PREFACE ………………………………………………………………………………. vi
I: INTRODUCTION …………………………………………………………………….. 1
1.1 PURPOSE OF STUDY.…………………………………………………….…... 3
1.2 NEED FOR STUDY……………………………………………………………. 3
1.3 LIMITATIONS…………………………………………………………………. 4
1.4 RELATED LITERATURE…………………………………............................... 4
1.5 DESIGN AND PROCEDURE………………………………………………….. 8
II: PAST AND PRESENT THEORISTS, DEFINITION, DIAGNOSIS AND CAUSES
AND EFFECTS ……......................................................................................................... 9
PART I: HISTORY .………………………………………………………………... 9
2.1 FREUD ..………………………………....………………..……………….. 10
2.2 JAMES ....................................................................................................…... 12
2.3 JUNG .......................................................................................................…...13
vii
PART II: CURRENT THOUGHT AND DEFINITION ….………………………..13
2.4 ELLIS……………………………………………………………….………..14
2.5 MAY………………………………………………………………................14
2.6 LANG………………………………………………………………………..16
2.7 BECK AND EMERY………………………………………………………..18
2.8 INGRAM AND KENDELL………………………………………................19
PART III: DIAGNOSIS……….……….……………………………………………20
2.9 AMERICAN PSYCHOLOGICAL ASSOCIATION………………….…….20
2.10 NATIONAL INSTITUTE OF MENTAL HEALTH………………….……21
PART IV: CAUSES AND EFFECTS …….………………………………………..26
III: TREATMENTS FOR PERFORMANCE ANXIETY …………………..…………..31
PART I: COGNITITVE-BEHAVIORAL THERAPY .…………………………….33
3.1 SYSTEMATIC DESENSITIZATION……………………….……………...34
3.2 ATTENTION TRAINING…………………………………………….……..35
3.3 BEHAVIORAL REHEARSAL……………………………………………...36
3.4 STRESS INOCULATION…………………………………………...............37
3.5 RELAXATION TECHNIQUES…………………………………..................38
3.6 FLOODING……………………………………………………………….…41
3.7 IMPLOSION THERAPY…………………………………………................41
PART II: PHARMACOLOGICAL TREATMENTS ..……………………………...42
3.8 BENZODIAZEPINES……………………………………………….………42
3.9 BETA-ADRENERGIC……………………………………………................44
3.10 BUSPIRONE.…..…………………………………………………………..45
3.11 TRICYCLIC ANTIDEPRESSANTS……………………………………....45
3.12 SELECTIVE SEROTONIN REUPTAKE INHIBITORS……….................47
viii
PART III: ALTERNATIVE TREATMENTS ..…………………….……………….48
3.13 EXERCISE………………………………………………..………………..49
3.14 NUTRITION………………………………………………………..………50
3.15 HERBS…………………………………………………………………..….50
3.16 HOMEOPATHY …………………………………………………………...53
3.17 ACUPUNCTURE………………………………………………..…………55
3.18 MEDITATION…………………………………………………….……….55
PART IV: TREATMENT FACILITIES ..…………………………………………..56
3.19 OUTPATIENT THERAPY PROGRAMS…………………...…...………..57
3.20 INPATIENT THERAPY CENTER ………………………….…………….60
IV: CONCLUSION ……………….…………………………………………………….63
REFERENCES ………………………………………………………………………….67
APPENDIX A ………………………………………………………………...…………77
APPENDIX B …………………………………………………………………...………86
ix
CHAPTER I
INTRODUCTION AND DEFINITION OF PERFORMANCE ANXIETY
Performance anxiety, often referred to as stage fright, is a recognized condition
that negatively affects numerous individuals in a wide variety of performance mediums.
The fear and anxiety associated with this condition may become so debilitating that the
affected individuals may be forced to relinquish the very activities that sustain their
careers and create life enjoyment. Performance anxiety refers to a condition a person
experiences while performing before an audience of any type or size. Webster’s New
Collegiate Dictionary defines anxiety as “a painful or apprehensive uneasiness of mind,
usually over an impending or anticipated ill.” 1 Performance anxiety is a multi-faceted
phenomenon involving cognitive, behavioral, and physiologic responses that resemble
fear, but occurs in the absence of a true threat, inappropriate to the reality of a threat, or
in response to some unknown stimulus. 2 Many types of performance anxiety prevail,
such as public-speaking anxiety, test anxiety, sports performance anxiety, and social
anxiety. Amateurs, students and performers in each of these fields encounter many
situations where they are required to perform in front of a live audience. For example,
1
Webster’s New Collegiate Dictionary, http://www.merriam-webster.com (accessed October 28,
2010).
2
Alan D. Reitman, “The Effects of Music-Assisted Coping Systematic Desensitization on Music
Performance Anxiety: A Three Systems Model Approach” (dissertation, Temple University, 1997), 10.
1
teachers are frequently expected to interact with others outside the classroom in venues
that require social communication interaction as well as performing daily in front of their
students. According to behavioral psychologists, an anxious response to a particular
event develops in one of three ways: 1) Directly experiencing the event, 2) Observing a
subject’s behavior in response to the event, or 3) Receiving information about the event. 3
As two of these three sources of the fear response are directly applicable to an
educational setting, it is critical that educators become knowledgeable about performance
anxiety related to musicians and the best ways to minimize its development.
A specific type of performance anxiety is Music Performance Anxiety (here after
referred to as MPA) in which a musician has a fear of failure, or the fear of a negative
evaluation from the audience based on potential problems that could occur during a
performance. 4 Anticipation of an event such as a concert, audition or a performance
examination triggers physiological and psychological fear responses. Unfortunately,
many musicians have the discouraging experience of not being able to perform at their
full capabilities because their anxiety level has risen high enough that their automatic
motor responses become lessened. One of the major theories regarding the origins of
MPA states that anxiety develops as a result of early learning experiences. 5 A related
theory would be that the acquisition or nonacquisition of MPA is directly related to one’s
3
D. Reubart, Anxiety and Musical Performance: On Playing the Piano from Memory (New York:
DaCapo Press, 1985), 65.
4
In a 1987 study, Nagal (“In Pursuit of Perfection: Career Choice and Performance Anxiety in
Musicians) found that 92% of music students reported experiencing stage fright and that 62% felt that their
performances were adversely affected by this experience of anxiety. McCoy, Lorraine H. “Musical
Performance Anxiety among College Students: An Integrative Approach,” dissertation (Northern Illinois
University, 1999).
5
Lorraine H. McCoy, “Musical Performance Anxiety Among College Students: An Integrative
Approach” (dissertation, Northern Illinois University, 1999), 23.
2
learning and/or development; a study of the origins could then offer new information
relevant to an educational intervention. 6 An understanding of the ways in which
performers differ both in their attitudes toward their experience of MPA and the ways in
which they utilize various coping mechanisms can offer guidelines for helping
performers overcome debilitating anxiety.
1.1 PURPOSE OF THE STUDY
Performance anxiety has long been recognized as a problem for musicians as well
as performers in other disciplines such as athletics, theater arts, and public speaking.
Anxiety is a concept that has been extensively studied as a factor in achievement and
education in many disciplines; however, relatively few studies have focused on music
performance anxiety. The study will delve into the physiological and psychological
causes of performance anxiety and the human responses engendered by the condition.
While other professions are actively involved with diagnosis and treatment of the
condition, diagnosis and treatment of the condition is still relatively new to the music
profession. The study will examine the causes of MPA as well as provide a summary of
current treatments. The purpose is to provide a basic resource guide for musicians
dealing with performance anxiety.
1.2 NEED
The magnitude and prevalence of disorders suffered by musicians with music
performance anxiety have prompted professionals from several disciplines, including
music performance, psychology, education and medicine to further their understanding of
performance-related stress. There have been relatively few studies on performance
6
E. E. Levitt, The Psychology of Anxiety (New York: Holt, Rinehart and Winston, 1967), 42.
3
anxiety and its effects on music performance quality. Additional research is needed to
clarify the effects of anxiety in this area. Furthermore, minimal research exists on the
effectiveness of techniques that may be used to control physical and psychological
responses associated with anxiety occurring during music performance, such as selfrelaxation techniques.
Considering the impact that music performance anxiety has on the quality of
performance, career development and mental health of music students and professionals,
more insight into performance anxiety may lead to enhanced communication between
student and teacher and better understanding of anxiety problems. The influence that
development and learning have on the origins of music performance anxiety may guide
musicians in realizing and diagnosing anxiety problems and determining solutions or
treatments.
1.3 LIMITATIONS
The purpose of the study is to provide a general definition of music performance
anxiety and its related disorders. The study will also discuss the causes of performance
anxiety and provide a current summary catalog of physiological, psychological,
pharmacological, and therapeutic treatments to alleviate performance anxiety. While
reference will be made to current research data and case studies, this study will be limited
to definitions and a survey of disorders and treatments.
1.4 RELATED LITERATURE
Monographs on performance anxiety focus on general musical performance
anxiety with the majority of authors developing specific methods for improvement or
relief from the condition. Recent monographs on performance anxiety include D.S.
4
Berger’s Toward the Zen of Performance: Music Improvisation Therapy for the
Development of Self-Confidence in the Performer which discusses using Zen philosophy
and free improvisation therapy as a way of discovering cognitive connections between
the performer and the music to alleviate performance anxiety. 7 Don Greene’s
Performance Success: Performing Your Best Under Pressure teaches a set of skills, such
as muscle awareness, mental focus, performance imagery, etc., to promote optimum
performance in anxiety-inducing settings. 8 Gary McPherson’s and Richard Parncutt’s
The Science and Psychology of Music Performance: Creative Strategies for Teaching
and Learning assembles current research findings and describes new approaches to
teaching music and learning music. 9 David Roland’s The Confident Performer examines
overwhelming levels of anxiety and suggests ways to manage and harness anxiety to
improve performance. 10
Recent unpublished research in the area of performance anxiety includes Mary
Elizabeth Taylor’s dissertation, Meditation as Treatment for Performance Anxiety in
Singers which presents the results of a self-reporting survey of members of the National
Association of Teachers of Singers and suggests how meditation might be used as a
treatment for performance anxiety. 11 Lisa Marie Sinden’s dissertation, Music
7
D.S. Berger, Toward the Zen of Performance: Music Improvisation Therapy for the
Development of Self-Confidence in the Performer (MMB Music, 1999), 12.
8
Don Greene, Performance Success: Performing Your Best under Pressure (New York:
Routledge, 2002), 17.
9
Gary McPherson and Richard Parncutt, The Science and Psychology of Music Performance:
Creative Strategies for Teaching and Learning (Oxford: Oxford University Press, 2002), 5.
10
David Roland, The Confident Performer (Sydney: Currency Press, 1997), 9.
11
Mary Elizabeth Taylor, “Meditation as Treatment for Performance Anxiety in Singers”
(dissertation, University of Alabama, 2001), 4.
5
Performance Anxiety: Contributions of Perfectionism, Coping Style, Self-Efficacy, and
Self-Esteem consists of a study of 138 university music students who were tested on four
areas of anxiety-inducing thinking using pre-existing evaluation scales. 12 Soo Young
Kim’s thesis, The Effect of Guided Imagery and Preferred Music Listening Versus
Guided Imagery and Silence on Musical Performance Anxiety divided eighteen volunteer
music students into experimental and control groups and measured the efficacy of guided
imagery in alleviating performance anxiety.13 Catherine Sweeney-Burton’s dissertation,
Effects of Self-Relaxation Techniques Training on Performance Anxiety and on
Performance Quality in a Music Performance Condition examines the effects of selfrelaxation on undergraduate music students performing in enhanced anxiety
environments. 14
The following internet resource sites provide current information in research and
materials available for use in overcoming performance anxiety. Sandy Nicholson’s
“Coping with Performance Anxiety” offers personal accounts from various musicians
plagued with performance anxiety with solutions/answers for each situation. 15 University
of Wisconsin-Eau Claire, “Coping with Music Performance Anxiety” focuses on the
cognitive distortions a performer tells himself/herself during an anxiety-filled moment
12
Lisa Marie Sinden, “Music Performance Anxiety: Contributions of Perfectionism, Coping
Style, Self-Efficacy, and Self-Esteem,” (dissertation, Arizona State University, 1999), 3.
13
Soo Young Kim, “The Effect of Guided Imagery and Preferred Music Listening Versus Guided
Imagery and Silence on Musical Performance Anxiety” (master’s thesis, Texas Woman’s University,
2002), 8.
14
Catherine Sweeney-Burton, “Effects of Self-Relaxation Techniques Training on Performance
Anxiety and on Performance Quality in Music Performance Condition,” (dissertation, University of North
Carolina at Greensboro, 1997), 2.
15
http://www.engr.unl.edu/eeshop/anxiety.html (accessed Oct. 8, 2010).
6
and teaches how to change these thinking patterns. 16 Karla Harby’s, “Beta Blockers and
Performance Anxiety in Musicians” provides advice on various beta-blockers
commercially available and proposes questions a musician should ask himself/herself
before beginning these types of medication.17
Online journals related to issues of performance anxiety include “Athletic Insight:
The Online Journal of Sports Psychology” which deals with the relationship between
anxiety and performance from a cognitive-behavioral perspective.18 The American
Psychological Association online journal provides current data on research in
psychology, including various forms of anxieties. 19 “Many Young Musicians Troubled
by Performance Anxiety” can be found in the Psychiatry Online Journal and gives an
overview of how teens are affected and how they cope with performance anxiety. 20
“What is Anxiety” is an article located in the Mental Health Matters online journal and
provides personal accounts from persons plagued with performance anxiety and the
measures they took to eliminate it from their lives. 21
David Leisner’s article, “Six Golden Rules for Conquering Performance
Anxiety,” from The American String Teacher suggests six “golden rules” to overcome
performance anxiety, such as self-judgment and second guessing oneself during a
16
http://www.uwec.edu/counsel/pubs/musicanxiety.html (accessed Oct. 8, 2010).
17
http://www.ethanwiner.com/BetaBlox.html (accessed Oct. 8, 2010).
18
http://www.athleticinsight.com/Vol1Iss2/Psychoanalytic_Anxiety.html (accessed Oct. 8, 2010).
19
http://www.apa.org/journals/amp/ (accessed Oct. 8, 2010).
20
http://pn.psychiatryonline.org/cgi/content/full/40/14/16-a (accessed Oct. 8, 2010).
21
http://www.mental-health-matters.com/articles/article.php?artID=470 (accessed Oct. 8, 2010).
7
performance. 22 “Managing Musical Performance Anxiety” by Joann Kirchner, from The
American Music Teacher, provides an overview of the physical problems associated with
performance anxiety. “Taming Performance Anxiety” by David W. Goodman, Ph. D., is
found in The Horn Call and delves into the physiological complications from
performance anxiety as well as specific treatments available, such as beta-blockers. 23
The Journal of the International Horn Society contains David Nesmith’s article, “Ease
Performance Anxiety Naturally” which encourages positive thinking during a selfjudgmental episode as well as attaining the ability to include one more non-threatening
thought, such as focusing attention on the feeling of the support of the chair below. 24
A scarcity of information in the research literature concerning the origins of MPA
in particular suggested the need for a study that would encompass all areas of interest
dealing with this problem. To date, there is not a cumulative survey of performance
anxiety, namely MPA, and its treatments for those suffering and wanting to alleviate such
problems.
1.5 DESIGN AND PROCEDURES
The study comprises four chapters, a bibliography, and appendices. Chapter one
consists of an introduction including the purpose, need, limitations, and related literature.
Chapter two provides a list of causes and effects of performance anxiety on musicians.
Chapter three includes treatments and therapies available. Chapter four consists of a
summary and conclusion.
22
23
http://www.davidleisner.com/articles.html (accessed Oct. 8, 2010).
http://www.idrs.org/publications/Journal/JNL18/JNL18.Goodman.Taming.html (accessed Oct.
8, 2010).
24
http://www.bodymap.org/articles/artperfanxiety.html (accessed Oct. 8, 2010).
8
CHAPTER II
PAST AND PRESENT THEORISTS, DEFINITION, CAUSE AND EFFECT, AND
DIAGNOSIS
PART I: HISTORY
Daily life throughout human history has been subject to real or perceived
situations of risk and danger. Perceived physical risks and dangers may result in an
individual experiencing feelings of heightened awareness, elevated heart rate, effects of
increased adrenaline production, nervousness and panic. As study of the human
condition evolved, various terms were used to describe these feelings experienced by
individuals in actual or perceived dangers or risks. An early precursor, termed “irritable
heart,” or “cardiac neurosis” described the association between psychological distress and
physical symptoms, particularly those involving the cardiac system. 25 The connection of
the psychological distress and the cardiac system may have developed as a rapid
heartbeat is one of the most apparent sensations of individuals experiencing anxiety.
With the development of modern psychological professions, these feelings and terms
have become part of a general rubric referred to as anxiety disorders.
25
Paul G. Salmon and Robert G. Meyer, Notes from the Green Room: Coping with Stress and
Anxiety in Musical Performance (New York: Lexington Books, 1992), 125-128. It was also known as Da
Costa’s syndrome, after the nineteenth-century surgeon who first described it; also termed neurocirculatory
aesthesia, nervous exhaustion, and even war neurosis.
9
2.1 SIGMUND FREUD
Sigmund Freud defined anxiety as:
Anxiety, then, is in the first place something felt. We call it an affective
state, although we are equally ignorant of what an affect is. As a feeling it
is of most obviously unpleasurable character, but this is not by any means
a complete description of its quality; not every state of unpleasure may we
call anxiety. There are other feelings of unpleasurable character (mental
tension, sorrow, grief). In addition to this characteristic so difficult to
define, we perceive more definite physical sensations, which we refer to
specific organs, as accompanying anxiety. The analysis of the anxiety
state gives us, then, as its attributes: (1) a specific unpleasurable quality,
(2) efferent or motor discharge phenomena, and (3) the perception of
these. Anxiety, therefore, is a specific state of unpleasure accompanied by
motor discharge along definite pathways. In accordance with our general
outlook, we shall believe that an increase of excitation underlies anxiety,
an increase which on the one hand is responsible for its unpleasurable
character and on the other is relieved through the discharge referred to.
The anxiety state is the reproduction of an experience which contains
within itself the requisite conditions for the increase in stimulation just
mentioned, and for its discharge via given pathways; and it is in virtue of
this, therefore, that the unpleasure element in anxiety acquires its specific
character. 26
Freud theorized that anxiety originated from the infant’s inability to master
excitations; the infant was exposed to more stimulation than he could possibly master.
The abundant stimulation was traumatic and created the painful feeling of primary
anxiety. Freud believed that birth trauma was the prototype of all future anxiety states.
Separation from the mother was another anxiety-producing experience. Freud also
believed that guilt feelings, fear of abandonment, and rejection were the most frequently
experienced anxiety-producing situations which may return in later life. The feeling of
being helpless was one of the main symptoms in practically all neuroses. The inability to
26
Sigmund Freud, The Problem of Anxiety (New York: The Psychoanalytic Quarterly Press and
W. W. Norton and Company, 1936), 90-99.
10
control excitation, whether stemming from sexual or aggressive impulses, created the
state of anxiety. 27
In the clinical field, “neurotic anxiety” was used by Sigmund Freud to describe a
pattern of distress that he believed afflicted almost everyone. 28 Freud believed the
intensity of anxiety varied considerably, and the circumstances evoked were comparably
variable. 29 Sigmund Freud’s characterization of anxiety neurosis was an early landmark
in the evolving concept of anxiety disorders. Freud initially distinguished two distinct
forms of anxiety: a) free-floating anxiety and b) signal theory of anxiety. Free-floating
anxiety was characterized as the sudden eruption into consciousness of acute discomfort
and as a consequence of the failure to drive (or repress) painful memories, impulses, and
thoughts from conscious awareness. A more sharply focused form of anxiety was
defined as the “signal” theory of anxiety, which viewed anxiety as a response to
impending danger either from within or outside the individual. The importance of the
signal theory of anxiety was that it characterized anxiety as an adaptive response to a
potential, realistic threat. 30 Freud later distinguished several subtypes of anxiety, which
he termed realistic, moral, and neurotic. Realistic anxiety corresponded to what is
commonly termed fear, the response to a genuine external threat. Moral anxiety was
defined as apprehension stemming from overly restrictive superego development.
Neurotic anxiety was defined as an exaggerated response to inner feelings and sensations
27
Sigmund Freud, Inhibitions, Symptoms and Anxiety (New York: W. W. Norton and Company,
1977), 74-175.
28
Freud, The Problem of Anxiety, 90-99.
29
Ibid.
30
Ibid.
11
misconstrued as threatening.
2.2 WILLIAM JAMES
As influential as Freud’s theories of anxiety were, other explanations developed
later. In the 1870s, Henry Holt produced a series of books entitled the American Science
Series. Holt desired a volume to include the new science of psychology, and in 1878 he
signed William James, an American psychologist, as his author. Ten years later James
produced this book in two volumes as The Principles of Psychology. 31 The subjects
covered in this book included consciousness, sensation, perception, association, memory,
attention, imagination, reasoning, emotions, and will. One of the key concepts of James’s
psychology was the stream of consciousness and its linkage to selective attention. Prescientific definitions of psychology had emphasized it as the study of the soul or the
study of the mind.
In the James/Lange theory of anxiety, William James and Danish physiologist
Carl Lange contended that emotions arose from our muscular and visceral responses to
threatening situations, moreover that physical responses to threats provoked the
emotional reactions. In 1884, the combined ideas of James and Lange described this
process as the following:
My theory…is that the bodily changes follow directly the perception of
the exciting fact, and that our feeling of the same changes as they occur is
the emotion. Common sense says, we lose our fortune, are sorry and
weep; we meet a bear, are frightened and run; we are insulted by a rival,
are angry and strike. The hypothesis here to be defended says that this
order of sequence is incorrect…and that the more rational statement is that
we feel sorry because we cry, angry because we strike, afraid because we
tremble…Without the bodily states following on the perception, the latter
would be purely cognitive in form, pale, colorless, destitute of emotional
31
William James, The Principles of Psychology, Vol. I and II (New York: Henry Holt and
Company, 1890).
12
warmth. We might then see the bear, and judge it best to run, receive the
insult and deem it right to strike, but we should not actually feel afraid or
angry. 32
2.3 CARL JUNG
Carl Jung, a contemporary of Freud and James, was fascinated by dynamic
and unconscious influences on human behavior. Jung, however, believed that the
unconscious contained more than repressed sexual and aggressive urges, as Freud
had theorized. His therapeutic approach emphasizes ways of helping patients
become aware of their unconscious aspects through dreams and fantasy material
and thus bringing the unconscious into the conscious awareness. 33 Such an
approach is designed to help individuals realize their unique psychological being.
This emphasis on the unconscious can be seen in the explanation of Jung’s theory
of personality and psychotherapy.
PART II: CURRENT THOUGHT AND DEFINITION
At present, the use of the term anxiety may be described as having two different
aspects. The first aspect concerns anxiety’s effect on how an individual thinks and feels.
Considerable evidence suggests that anxiety is accompanied by habitual patterns of
thought. The second aspect focuses on how anxiety apparently limits basic cognitive
capabilities such as memory and attention. For the performing musician, both of these
aspects may have important implications.
32
Carl Georg Lange and William James, The Emotions (New York: Hafner, Pub. Co., 1967) 78.
33
Richard S. Sharf, Theories of Psychotherapy and Counseling: Concepts and Cases (Australia:
Thomson, Brooks/Cole, 2004), 79.
13
2.4 ALBERT ELLIS
Developed by Albert Ellis, rational emotive behavior therapy (REBT) focuses on
irrational beliefs that individuals develop that lead to problems related to emotions (for
example, fears and anxieties) and to behaviors (such as avoiding social interactions or
giving speeches). Although REBT uses a wide variety of techniques, the most common
method is to dispute irrational beliefs and to teach clients to challenge their own irrational
beliefs so that they can reduce anxiety and develop a full range of ways to interact with
others. 34
2.5 ROLLO MAY
Humanist psychologist, Rollo May, views anxiety as part of the human condition
and cannot be eradicated. May defines anxiety as “the apprehension cued off by a threat
to some value which the individual holds essential to his existence as a self.” 35 May
believes that anxiety is linked to the realization that human existence is tenuous. Dealing
with anxiety thus entails exploring the vulnerabilities that underlie it, rather than
attempting to eliminate or minimize it. 36 The most important emergent capacity in the
human being is self-relatedness. May explains that the distinctive quality of human
anxiety arises from the fact that man is the valuing animal, the being who interprets his
life and world in terms of symbols and meanings, and identifies these with his existence
as a self. It is a threat to these values that causes anxiety. May also differentiates normal
anxiety from neurotic anxiety. Normal anxiety is anxiety which is proportionate to the
34
Ibid., 7-8.
35
Rollo May, Psychology and the Human Dilemma (New York: W. W. Norton and Company,
1979), 72.
36
Ibid., 130.
14
threat, does not involve repression, and can be confronted constructively on the conscious
level. Neurotic anxiety is a reaction which is disproportionate to the threat, involves
repression and other forms of intrapsychic conflict, and is managed by various kinds of
blocking-off of activity and awareness. Neurotic anxiety develops when a person has
been unable to meet normal anxiety at the time of the actual crisis in his growth and the
threat to his values. Neurotic anxiety is the end result of previously unmet normal
anxiety. 37
Many psychologists have argued that anxiety is a part of the “human condition”.
A brief reflection on the many uncertainties one must face may convince individuals that
life offers no lasting peace of mind. The apprehension many individuals feel may partly
stem from awareness of human frailty and vulnerability. From this vantage point, anxiety
may appear to be a normal part of our psychological make-up.
An explanation for anxiety’s widespread prevalence may be its link to a very
primitive self-protection mechanism termed the “fight or flight” response, which virtually
all mammals possess. 38 Central to this response is physical activation that has much in
common with feelings that derive from anxious thoughts. The fight or flight response
may trigger profuse sweating, moist hands and feet, rapid breathing, a perceptible
increase in heart rate, among other symptoms. Although the experience of these
sensations is often unpleasant, they actually serve the useful purpose of mobilizing a
person to take some sort of immediate action in response to a perceived threat stimulus.
This response may have evolved as a means of responding to direct physical threats, such
37
Ibid., 80.
38
Salmon and Meyer, 125-128.
15
as an attack by a wild animal in prehistoric times. Now that there are seldom occurrences
of such attacks, this response is usually elicited by situations that pose psychological
threats. Facing a large audience as a soloist may serve as an example of a psychological
threat, at least to the degree that the performer finds this experience challenging and
frightening. Although the risk of physical harm is quite low, such circumstances may
trigger the reactions that accompany the fight or flight response. 39
Despite the widespread contemporary acceptance of anxiety as a signal or
warning system, anxiety loses much of its adaptive value when it becomes a maladaptive
response that interferes with effective coping. A pianist who feels overcome by stage
fright may experience an appropriate degree of anxiety evoked by the prospect of being
watched by others. This response may cause the performer to become more alert and
careful while playing. But if the intensity of the anxiety becomes elevated beyond a level
considered “normal” it may cause problems, such as technical errors, memory loss, or
loss of motor control, that were factors overcome in the learning process.
2.6 PETER LANG
The psychologist Peter Lang and his associates developed an important threefactor contemporary model of anxiety connecting the earlier Freudian perspective to one
that incorporates a broader range of contributory factors. Emotional states, such as
anxiety, arise from an interaction between three psychological components: cognitive,
behavioral, and physiological. The cognitive component is represented by thoughts and
related mental images of risk or danger. The behavioral side of anxiety is a tendency to
avoid or escape from anything perceived as dangerous. The physiological component of
39
Ibid., 125-128.
16
anxiety involves the somatic reactions that accompany heightened arousal. Even though
these three psychological components all appear to be involved in anxiety, they are not
necessarily present to the same degree or at the same time.
Lang defines the presence and interaction of the cognitive, behavioral and
physiological factors as response system desynchrony. 40 Desynchrony may be illustrated
by imagining three ensemble players who play “out of synch” with each other. The
degree of response system desynchrony varies according to the intensity of a person’s
anxiety, so that desynchrony is greatest at low levels of anxiety and least at higher levels.
Cognitive, behavioral and physiological factors involved in desynchrony provide
diagnostically useful information. For example, the presence of all three components
suggests extreme anxiety and substantial response synchrony. A situation in which
behavioral and cognitive components are evident without a physiological response may
reflect the effects of medications like beta blockers, which selectively reduce arousal
without substantially altering behavioral or cognitive capabilities. Mild anxiety could be
represented by troublesome thoughts without significant physiological arousal or
avoidance.
Lang’s three-factor theory of anxiety may offer a number of advantages over
previous formulations. First, it ascribes a significant role in anxiety to both overt
(behavioral) and covert (physiological and cognitive) components. Second, it accounts
for the observation that the different components of anxiety may be only moderately
correlated except under conditions of intense anxiety. Third, it acknowledges that the
40
P.J. Lang, G.A. Miller, and D. Levin, “Anxiety and Fear,” in, Consciousness and SelfRegulation, R.J. Davidson, G.E. Schwartz, and D. Shapiro, eds. (New York: Plenum, 1988), 123-51.
17
activation of any one of these three anxiety systems can in turn stimulate the others. 41
The key to this model lies in evidence that thoughts contribute to anxiety when one
appraises situations and concludes that there is danger.
2.7 AARON BECK AND GARY EMERY
Belief systems and thinking are seen as important in determining and affecting
behavior and feelings. Aaron Beck developed an approach that helps individuals
understand their own maladaptive thinking and how it may affect their feelings and
actions. Cognitive therapists use a structured method to help their clients understand
their own belief systems. By asking clients to record dysfunctional thoughts and using
questionnaires to determine maladaptive thinking, cognitive therapists are then able to
make use of a wide variety of techniques to change beliefs that interfere with successful
functioning. They also make use of affective and behavioral strategies. 42
Two contemporary psychologists, Aaron Beck and Gary Emery, argue that
disabling anxiety reflects cognitive activity in which a person, a) believes himself to be in
imminent danger; and b) feels inadequately prepared to deal with the threat. These two
features apply to situations of both focused and diffused anxiety. The complex response
pattern comprising anxiety may be oriented toward the outside environment or diffuse
internal sensations. 43
41
Ibid., 122-51.
42
Sharf, 8.
43
Aaron T. Beck and Gary Emerson, Anxiety Disorders and Phobias (New York: Basic Books,
Inc., Publishers, 1985), 66-81.
18
2.8 RICK INGRAM AND DAVID KENDALL
Psychologists Rick Ingram and David Kendall provide a helpful working model
of anxiety. Anxiety reflects the interaction of a) certain critical features, b) broader
characteristics associated with psychological distress, and c) a component reflecting
individual differences in reaction. 44 Among the principal critical features of anxiety is
the perception of danger. In addition, anxiety is self-perpetuating and often includes a
tendency to worry about the future. Most people who feel anxious are troubled by what
might happen rather than by current or past events. Coupled with this concern about the
future is the corresponding belief that they will not be able to cope with the anticipated
danger.
The functional impairments frequently associated with anxiety are intensified,
according to Ingram and Kendall, by aspects of the condition common to most other
forms of psychological distress. These include a) heightened self-absorption, b) the
activation of automated thought patterns (schemas), and c) limitations on the
effectiveness with which information is being processed. In this model, anxiety is
mediated by a variety of individual difference factors including, constitutional factors,
personal coping skills, perceived self-efficacy, and an individual’s habitual mode of what
has been termed “self-presentation.” 45
There are two primary anxiety syndromes: “exogenous” and “endogenous.”
“Exogenous” or “stimulus dependent” anxiety, is provoked by external stimuli, and
“endogenous” or “stimulus independent” anxiety, is not triggered by any identifiable
44
Rick E. Ingram and Philip C. Kendall, “The Cognitive Side of Anxiety“ in, Cognitive Therapy
and Research, Philip C. Kendall, ed. (New York: Plenum Publishing Company, 1987), 523-533.
45
Ibid., 523-533.
19
stimulus in the environment. 46
PART III: DIAGNOSIS
2.9 AMERICAN PSYCHIATRIC ASSOCIATION
In 1980, the American Psychiatric Association adopted rules for the assignment of
diagnoses of anxiety disorders:
1. When an Organic Mental Disorder can account for the individual’s symptoms
a nonorganic diagnosis is excluded.
2. A less pervasive diagnosis is not given when its defining symptoms are
symptoms associated with a more pervasive disorder.
3. An individual assigned an anxiety disorder may be given an additional
diagnosis of an anxiety disorder if the focus of his or her concern is not related to
the first diagnosis. 47
Generalized anxiety disorder, or GAD, was recognized by the American
Psychiatric Association when a person has an anxious mood or worried preoccupations
present on most days for at least six months. At least six of the eighteen symptoms must
be present during this period. The symptoms fall into three clusters:
1. Muscle tension: restlessness, shakiness, trembling, twitching, fidgeting,
muscle aches, easy fatigability.
2. Autonomic hyperactivity: rapid pulse, sweating, cold clammy hands, dry
46
Cynthia G. Last and Michael Hersen, Handbook of Anxiety Disorders (New York: Pergamon
Press, 1988), 42.
47
Diagnostic and Statistical Manual of Mental Disorders III (Washington DC: American
Psychiatric Association, 1980), 386-390.
20
mouth, dizziness, digestive disturbances, hot or cold flashes, frequent urination, a
sensation of a lump in the throat.
3. Vigilance and scanning: exaggerated startle response, difficulty concentrating,
insomnia, irritability, feeling on edge. 48
The causes of anxiety are numerous, and there are a host of diagnoses in which
anxiety is a prominent symptom. To detect an anxiety disorder, the evaluation of the
anxious individual must include a thorough review of symptoms and medical history.
Also, the diagnosis assigned will depend on the nature of the anxiety symptoms, the type
of stimulus that precipitates the anxiety, and the duration of the symptoms themselves.
2.10 NATIONAL INSTITUTE OF MENTAL HEALTH
The National Institute of Mental Health currently recognizes GAD in a patient
when he/she meets the following criteria:
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than
not for at least six months, about a number of events or activities (such as work or school
performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six
symptoms (with at least some symptoms present for more days than not for the past six
months). Only one item is required in children.
1. Restlessness or feeling keyed up or on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying
sleep)
D. The focus of the anxiety and worry is not confined to features of another Axis I
disorder such as having a panic attack (as in Panic Disorder), being embarrassed in public
(as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being
away from home or close relatives (as in Separation Anxiety Disorder), gaining weight
48
Ibid.
21
(as in Anorexia Nervosa), having multiple physical complaints (as in Somatization
Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry
do not occur exclusively during Posttraumatic Stress Disorder.
E. The anxiety, worry, or physical symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
F. The disturbance is not due to the direct physiological effects of a substance (for
example, a drug of abuse, a medication) or a general medical condition (for example,
hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic
Disorder, or a Pervasive Developmental Disorder. 49
DIAGNOSTIC FEATURES
The essential feature of GAD is excessive anxiety and worry (apprehensive
expectation), occurring more days than not for a period of at least six months, about a
number of events or activities (Criterion A). The individual finds it difficult to control
the worry (Criterion B). The anxiety and worry are accompanied by at least three
additional symptoms from a list that includes restlessness, being easily fatigued,
difficulty concentrating, irritability, muscle tension, and disturbed sleep (only one
additional symptom is required in children) (Criterion C). The focus of the anxiety and
worry is not confined to features of another Axis I disorder such as having a panic attack
(as in Panic Disorder), being embarrassed in public (as in Social Phobia), being
contaminated (as in Obsessive-Compulsive Disorder), being away from home or close
relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa),
having multiple physical complaints (as in Somatization Disorder), or having a serious
illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively
during Posttraumatic Stress Disorder (Criterion D). Although individuals with GAD may
not always identify the worries as “excessive,” they report subjective distress due to
49
Michael R. Liebowitz, ed., Diagnostic and Statistical Manual of Mental Disorders IV
(Washington DC: American Psychiatric Association, 2000), 472-476.
22
constant worry, have difficulty controlling the worry, or experience related impairment in
social, occupational, or other important areas of functioning (Criterion E). The
disturbance is not due to the direct physiological effects of a substance (for example, a
drug of abuse, a medication, or toxin exposure) or a general medical condition and does
not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive
Developmental Disorder (Criterion F). 50
The intensity, duration, or frequency of the anxiety and worry is far out of
proportion to the actual likelihood or impact of the feared event. The person finds it
difficult to keep worrisome thoughts from interfering with attention to tasks at hand and
has difficulty stopping the worry. Adults with GAD often worry about everyday, routine
life circumstances such as possible job responsibilities, finances, the health of family
members, misfortune to their children, or minor matters (such as household chores, car
repairs, or being late for appointments). Children with GAD tend to worry excessively
about their competence or the quality of their performance. During the course of the
disorder, the focus of worry may shift from one concern to another. 51
ASSOCIATED FEATURES AND DISORDERS
Associated with muscle tension, there may be trembling, twitching, feeling shaky,
and muscle aches or soreness. Many individuals with GAD also experience somatic
symptoms (for example, sweating, nausea, or diarrhea) and an exaggerated startle
response. Symptoms of autonomic hyper arousal (for example, accelerated heart rate,
shortness of breath, dizziness) are less prominent in GAD than in other Anxiety
50
Ibid.
51
Ibid.
23
Disorders, such as Panic Disorder and Posttraumatic Stress Disorder. Depressive
symptoms are also common.
GAD very frequently coincides with Mood Disorders (for example, Major
Depressive Disorder or Dysthymic Disorder), with other Anxiety Disorders (for example,
Panic Disorder, Social Phobia, Specific Phobia), and with Substance-Related Disorders
(for example, Alcohol or Sedative, Hypnotic, or Anxiolytic Dependence or Abuse).
Other conditions that may be associated with stress (for example, irritable bowel
syndrome, headaches) frequently accompany GAD. 52
SPECIFIC CULTURE, AGE, AND GENDER FEATURES
There is considerable cultural variation in the expression of anxiety (for example,
in some cultures, anxiety is expressed predominantly through somatic symptoms, in
others through cognitive symptoms). It is important to consider the cultural context when
evaluating whether worries about certain situations are excessive.
In children and adolescents with GAD, the anxieties and worries often concern
the quality of their performance or competence at school or in sporting events, even when
their performance is not being evaluated by others. There may be excessive concerns
about punctuality. They may also worry about catastrophic events such as earthquakes or
nuclear war. Children with the disorder may be overly conforming, perfectionist, and
unsure of themselves and tend to redo tasks because of excessive dissatisfaction with
less-than-perfect performance. They are typically overzealous in seeking approval and
require excessive reassurance about their performance and their other worries.
GAD may be over diagnosed in children. In considering this diagnosis in
52
Ibid.
24
children, a thorough evaluation for the presence of other childhood Anxiety Disorders
should be done to determine whether the worries may be better explained by one of these
disorders. Separation Anxiety Disorder, Social Phobia, and Obsessive-Compulsive
Disorder are often accompanied by worries that may mimic those described in GAD. For
example, a child with Social Phobia may be concerned about school performance because
of fear of humiliation. Worries about illness may also be better explained by Separation
Anxiety Disorder or Obsessive-Compulsive Disorder.
In clinical settings, the disorder is diagnosed somewhat more frequently in women
than in men (about 55-60% of those with the disorder are female). In epidemiological
studies, the sex ratio is approximately two-thirds female. 53
PREVALENCE
In a community sample, the one-year prevalence rate for GAD was approximately
3%, and the lifetime prevalence rate was 5%. In anxiety disorder clinics, up to a quarter
of the individuals have GAD as a diagnosis. 54
COURSE
Many individuals with GAD report that they have felt anxious and nervous all
their lives. Although over half of those presenting for treatment report onset in childhood
or adolescence, onset occurring after age 20 years is not uncommon. The course is
chronic but fluctuating and often worsens during times of stress. 55
53
Ibid.
54
Ibid.
55
Ibid.
25
FAMILIAL PATTERN
Anxiety as a trait has a familial association. Although early studies produced
inconsistent findings regarding familial patterns for GAD, more recent twin studies
suggest a genetic contribution to the development of this disorder. Furthermore, genetic
factors influencing risk of GAD may be closely related to those for Major Depressive
Disorder. 56
When anxiety is present with no current or past history of panic attacks, GAD is
the diagnosis. Presently, the Diagnostic and Statistical Manual of Mental Disorders states
that there are two types of generalized anxiety disorder. Type one is a traumatic event,
involving actual injury or threat of injury or a threat to a personal relationship. The most
dramatic expression of type one disorder is the “combat neurosis” characterized by a
subject who has experienced catastrophic events in battle. A similar reaction is seen in
less dramatic ways in civilian life and may be precipitated by a frightening event such as
a surgical operation or observing injury to another individual. These traumatic reactions
are found most commonly in acute anxiety states. The second type of generalized
anxiety disorder is an extension and aggravation of fears that an individual had
experienced during his early development, which continued to be a chronic problem. 57
PART IV: CAUSES AND EFFECTS
A wide range of terms and concepts have been used to describe anxiety. “Fear,”
“phobia,” “nervousness,” and “panic” are among the words used interchangeably with
56
Ibid.
57
Beck and Emery, 88-89.
26
“anxiety.” One of the most troublesome features of anxiety is the way it may become
overwhelming to a person in the absence of corrective, regulatory feedback. This effect,
which has been noted by many investigators, arises from the fact that different
components of anxiety - thoughts, physical responses, and behavior patterns - may be
both stimuli and responses to one another.
Physiological characteristics of anxiety include an increase in heart rate, an
increase in the excretion of both epinephrine and cortisol, and to a lesser extent, an
increase in the excretion of norepinephrine. 58 This increase of norepinephrine excretion
varies due to the degree of stage fright. 59 Other characteristics are muscle tremor,
sweating, confusion, dry mouth, hyperventilation and nausea. 60 Both epinephrine and
norepinephrine are classified as catecholamines and are produced in the medulla part of
the adrenal gland, located on the top of the kidneys as well as in the central and
peripheral nervous systems. 61 Norepinephrine is the major neurotransmitter for the
peripheral sympathetic nervous system. 62
58
Mats Fredrikson and Robert Gunnarsson, “Psychobiology of Stage Fright: The Effect of Public
Performance on Neuroendocrine, Cardiovascular, and Subjective Reactions,” in Biological Psychology 33
(Elsevier Science Publishers, 1992), 51-52. The Merriam-Webster Medical Dictionary defines epinephrine
as a hormone that is the principal blood-pressure-raising hormone secreted by the adrenal medulla, is
prepared from adrenal extracts or made synthetically, and is used medicinally especially as a heart
stimulant. As a stress hormone, norepinephrine affects parts of the brain where attention and responding
actions are controlled. Along with epinephrine, norepinephrine also underlies the fight-or-flight response,
directly increasing heart rate, triggering the release of glucose from energy stores, and increasing blood
flow to skeletal muscle. Cortisol is a hormone produced in the adrenal cortex, which is a part of the adrenal
gland. It is usually referred to as the stress hormone as it is involved in response to stress and anxiety.
59
Ibid.
60
Don Greene, Fight Your Fear (New York: Broadway, 2001), 47-48.
61
Catecholamine is an amine derived from the amino acid tyrosine -- examples include
epinephrine (adrenaline), norepinephrine (noradrenaline), and dopamine -- that act as hormones or
neurotransmitters.
62
Mikel A. Rothenberg and Charles F. Chapman, Dictionary of Medical Terms for the
Nonmedical Person, 4th ed. (Hauppauge, NY: Barron’s Educational Series, 2000), 104.
27
Coordinated motions and feelings of the body are controlled by the central
nervous system, which is composed of the brain and the spinal cord. 63 The peripheral
nervous system is a network of nerves that extends to all the extremities of the body.
This system sends signals to and from the central nervous system, controlling all
voluntary actions and sensory perceptions. 64 The individual nerve cells, or neurons, carry
electrical impulses away via their axons, and impulses are carried towards them via
structures known as dendrites. Sensory neurons involved with feelings transmit impulses
to the central nervous system, and motor neurons transmit impulses from the central
nervous system to the muscles and glands. 65
These impulses can be transmitted between either two neurons or between a
neuron and muscular tissue or gland cells. 66 On an electron microscopic level, these
impulses are transmitted via the action of neurotransmitting chemicals, or
neurotransmitters, such as norepinephrine mentioned above. 67 The impulse sites are
known as synapses, first proposed by Sherrington in 1906. 68 Within these sites, the
neurotransmitting chemicals are released from presynaptic nerve terminals, bulb-like
structures at the end of nerve axons called boutons, into a structure called the synaptic
63
Ibid., 108-109.
64
Ibid., 433.
65
Ibid., 389.
66
Ibid., 536.
67
John C. Eccles, “Developing Concepts for the Synapses,” in The Journal of Neuroscience 10
(12) (Gottingen, Federal Republic of Germany: Max-Planck-Institut fur Biophysikalische Chemie, 1990),
3774.
68
Charles Sherrington, The Integrative Action of the Nervous System (New York: Charles
Scribner’s Sons, 1906), 17.
28
cleft. 69 Such chemical transmission is happening continuously.
Such chemical transmission by the neurotransmitting chemicals described in the
process above, are the basis of how we act, think and feel. 70 In musicians, the processes
of acting, thinking and feeling are developed to a high level of artistic sophistication in
both practice and performance. Stage fright interferes with this artistic process. 71
Of all the symptoms of anxiety, fear of the future is perhaps the most common.
Anxious individuals expect negative things to happen to them, even though most of their
predictions are never realized. The significance of this future orientation is especially
important when one considers the therapeutic implications. It is well known that active
rehearsal and visualization of anticipated stressors is part of the “work of worry” of
people confronting stressful events. 72 Novice and experienced persons differ in the
timing of anxiety versus the degree of anxiety. A study was performed using experienced
and inexperienced musicians, who were asked to retrospectively assess their anxiety at
three different points leading to an important performance and during the performance
itself. The inexperienced musicians experienced peak anxiety during the performance,
when they were least equipped to cope with it. The more experienced musicians, in
contrast, felt less anxious during the performance than prior to it. Many of the latter
reported anticipating, through visualization and mental rehearsal, the circumstances of the
69
Eccles, 3773. Bouton is a terminal club-shaped enlargement of a nerve fiber at a synapse with
another neuron. Synaptic cleft is the space between neurons at a nerve synapse across which a nerve
impulse is transmitted by a neurotransmitter.
70
Jaak Panksepp, “A Role for Affective Neuroscience in Understanding Stress: The Case for
Separation Distress Circuitry,” in Psychobiology of Stress, Stefano Puglisi-Allegra, and Alberto Oliverio,
eds. (Dordrecht, Netherlands: Kluwer Academic Publishers, 1990), 45.
71
Frederickson and Gunnarsson, 58.
72
Salmon and Meyer, 134.
29
performance and thus worked through the worst of the anxiety in advance. 73
The threat posed by the prospect of an inherently stressful situation can focus
anxiety and channel apprehension. Many anxious individuals seem to benefit from
planning and carrying out activities that involve dealing with a stressor. For example,
one musician with chronic anxiety found that during the concert season her anxiety was
quite low between performances, but peaked sharply shortly before each performance
engagement. In contrast, she reported moderate but chronic anxiety during the late spring
and summer months when she had fewer opportunities to perform. She preferred the
former situation because of the emotional variety afforded by periods of tension and
relaxation and because of the intense relief she experienced after her performances and
for long periods of time between concerts. 74
A great deal of evidence suggests that judgments have a significant impact on
how a person feels. The connection between thoughts, feelings, and behaviors is not as
direct as often perceived, despite the appealing claims of those who advocate such
theories as “positive thinking.” An individual never observes thoughts directly making it
difficult to perceive thoughts as concrete objects. However, some basic ideas about the
human thought process may give clues to how thoughts affect behavior, including
performance skills. 75
73
Ibid.
74
Ibid.
75
Ibid., 153.
30
CHAPTER III
THERAPIES AND TREATMENTS FOR PERFORMANCE ANXIETY
All of the therapies and treatments discussed in the following chapter are for
information only and do not serve as an endorsement of any information contained
herein. Interested persons should consult with a physician or psychologist prior to
beginning a treatment.
Various therapies and treatments exist for the management, alleviation or relief of
performance anxiety. For the purpose of this study, “therapy” will be used in
psychological references and “treatments” will be used in pharmacological references.
The following is a list of therapies and treatments with brief explanations. Each will be
discussed in detail later in the paper.
•
Cognitive-Behavioral Therapies
1. Systematic Desensitization -- progressive exposure to a fear hierarchy to
replace anxious feelings with relaxation.
2. Attention Training – focus of attention.
3. Behavior Rehearsal – practicing a newly learned behavior.
4. Stress Inoculation – Just as an inoculation to prevent measles puts stress on a
person’s biological system to prevent the development of measles, giving
individual’s an opportunity to cope with relatively mild stress stimuli
successfully allows them to tolerate stronger fears or anxieties.
31
5. Relaxation Techniques – breathing awareness, progressive muscle relaxation
and mental imagery.
6. Flooding – an individual is exposed to the mental image of a frightening or
anxiety-producing object or event and continues to experience the image of
the event until the anxiety gradually diminishes.
7. Implosion Therapy – a type of flooding, but the scenes are exaggerated rather
than realistic, and hypotheses are made about stimuli in the scene that may
cause the fear or anxiety.
•
Pharmacological Treatments
1.
Benzodiazepines - a group of drugs that help reduce anxiety and have
sedating effects. They work quickly, but they can be habit forming and are
usually prescribed for short-term use.
2. Beta-adrenergic - a group of drugs that specifically inhibit peripheral
autonomic symptoms. They are not habit forming, but are less effective than
benzodiazepines.
3. Buspirone - an anti-anxiety drug that must be taken for two weeks before
feeling any effect. There is no apparent drowsiness or dependency linked
with buspirone.
4. Tricyclic Antidepressants - a group of drugs originally used to treat
depression, and then later found effective with a variety of anxiety disorders.
5.
Selective Serotonin Reuptake Inhibitors (SSRI) - a group of drugs that reduce
the reabsorption of serotonin into the body, therefore increasing the levels of
serotonin in circulation. Management of serotonin levels is believed to
32
alleviate depression and anxiety.
•
Alternative Treatments
1. Exercise
2. Nutrition
3. Herbs
4. Homeopathy
5. Acupuncture
6. Meditation
•
Over-the-counter
There are no over-the-counter treatments for alleviating anxiety.
PART I: COGNITIVE - BEHAVIORAL THERAPY
Behavior therapy arose in the early twentieth century, in part, as a reaction against
the “excesses” of Freudian psychoanalysis. “Behavior and cognitive therapeutic
approaches to intervention are, by comparison with traditional psychoanalytic methods,
methodical, detached, and scientific.” They are unconcerned about the origin of a
maladaptive behavior except to identify the environmental stimulus that conditioned it,
thus indicating the plan of treatment. In therapy, total concentration is upon eliminating
the symptoms associated with the undesirable behavior. Behaviorists believe that, in the
name of science, the only valid indices of behavior are those that can be measured:
cognitive, behavioral and physiological patterns of change. All behaviorists recognize
that anxiety is a learned emotional response: conditioned responses derived from the
33
environment. 76
3.1 SYSTEMATIC DESENSITIZATION
Some standard behavioral approaches for the treatment of phobias have been
applied to music performance anxiety. The best known is systematic desensitization,
which involves training in muscular relaxation followed by having scenes that evoke
increasingly fearful or anxious reactions within the client (progressive exposure to a fear
hierarchy). A list of threatening images is derived from interviews with the subject and
arranged in a hierarchy from the least to most severe. The subject is then taught
progressive relaxation, and, at successive sessions, after he has reached an advanced state
of relaxation, is asked to visualize (or under live circumstances) one of these scenes at a
time, starting with the least threatening. The object is to remain relaxed while visualizing
each of these scenes, interrupting the visualization whenever anxiety enters. Extinction
of the anxiety is sought in the pairing of the noxious stimulus (the visualization with
feelings of comfort). When the most threatening scene can be visualized without tension,
therapy is considered to be complete. 77
Two studies on music performance anxiety that utilized systematic desensitization
are Wardle’s instrumental players in a sight-reading scenario78 and Appel’s solo pianists
under public performance conditions. 79 Both studies came to essentially the same
76
Dale Reubart, Anxiety and Musical Performance: On Playing the Piano from Memory (New
York: Da Capo Press, 1985), 184.
77
Reubart, 182-183.
78
A. Wardle, “Behavioral Modification by Reciprocal Inhibition of Instrumental Music
Performance Anxiety.” In C. K. Madsen, R. D. Greer, and C. H. Madsen, Jr. (eds.), Research in Music
Behavior: Modifying Music Behavior in the Classroom (N.Y.: Columbia University, Teachers College
Press, 1975).
79
Sylvia S Appel, “Modifying Solo Performance Anxiety in Adult Pianists,” Journal of Music
Therapy (Vol. XIII, No. 1, Spring, 1976): 2-16.
34
conclusion: that systematic desensitization training did lower the levels of performance
anxiety. Appel’s study (which does not specify whether the pianists were performing by
memory or not) placed anxious subjects who were given training in systematic
desensitization against a similar group of subjects who were given additional instruction
in musical analysis and another which received no instruction at all. The first group
benefited most, followed by the group having only musical analysis. In the Appel study
the anxiety hierarchy was encountered under live circumstances rather than through
imagery. However, exposure by itself does not necessarily extinguish performance
anxiety, since many musicians perform for years without ever conquering their fears
spontaneously (Wesner, 1990). 80
Targeting a phobic person’s behavior is sometimes insufficient for treating the
underlying anxiety because the way a person thinks about his or her situation is critical to
the onset of the anxiety. Since negative self-talk often mediates performance anxiety, it
follows that some form of cognitive restructuring, such as reorganizing the individual’s
habitual ways of thinking during the performance, might be helpful. 81
3.2 ATTENTION TRAINING
An important target for most cognitive procedures is the performer’s focus of
attention. Kendrick et al. (1982) showed the effectiveness of a procedure called attention
training with a group of 53 pianists who sought help for performance anxiety. This
consisted of the identification of negative and task-irrelevant thoughts during piano
playing and training in substituting for them optimistic, task-oriented self-talk.
80
Richard Parncutt and Gary E. McPherson, The Science an Psychology of Music Performance:
Creative Strategies for Teaching and Learning (New York: Oxford University Press, 2002), 52.
35
Improvement was compared against behavior rehearsal (playing repeatedly before
friendly, supportive audiences) and a wait-list control. Both treatments were clearly
superior to the wait-list control, but on some assessment criteria, attention training was
superior to behavior rehearsal. The authors acknowledged that their treatment included
many elements, such as verbal persuasion, modeling, instruction, performance
accomplishments, group influence, and homework assignments, but nevertheless felt that
the key element to their treatment was the modification of maladaptive thoughts. 82
Subsequent research provides some backing for this conclusion. In a trial of
cognitive therapy versus anti-anxiety drugs, Clark and Agras (1991) found that betablockers were no more effective than placebo, but cognitive restructuring was clearly
superior to both. Sweeney and Horan (1982) reported that both cognitive therapy and
cue-controlled relaxation training were individually superior to a control condition that
consisted of musical analysis training, but the combination of cognitive therapy and
relaxation was best of all. 83 Though attention training has shown to be effective during a
performance, it is also important to address anticipated thoughts or physical reactions
before a performance.
3.3 BEHAVIOR REHEARSAL
Behavioral rehearsal is somewhat similar to flooding, as under live circumstances,
which involves practicing a newly observed behavior in order to strengthen this new
observation. Margaret Kendrick’s review of the literature on behavior rehearsal
concluded that it is helpful “so long as the subject perceives the experience as one of
81
Ibid., 53.
82
Ibid.
36
success (or, at least, of less danger to his well-being than he had supposed) - one in which
the threat is viewed, both before and after the fact, as one that he can handle (and one that
he does) without reinforcement of the initial response.” 84
3.4 STRESS INOCULATION
A particular form of cognitive restructuring that shows promise is stress
inoculation (Meichenbaum, 1985; Salmon, 1991). The idea is that it is important to
implant realistic expectations about what will be experienced during performance, as well
as promoting optimistic self-comments. Performers are taught to anticipate the
symptoms of anxiety that are bound to arise before important public appearances and to
accept them, that is, reframe them as less threatening, even desirable, reactions. For
example, the adrenaline effects (pounding heart, faster breathing) are reappraised as
normal emotional responses that are not conspicuous to an audience and can provide
energy, thus contributing to a livelier, exciting musical performance. 85
In an interview study with successful professional performers, Roland (1994a)
found that they viewed anxiety or nervousness before a performance as a normal and
even a beneficial part of performance preparation. They described experiencing an
excited feeling before performing, an increase in mental focus, and sometimes
inspiration. Similarly, Hanton and Jones (1999) found that elite swimmers viewed precompetition anxiety more helpful to a far greater extent than non-elite swimmers.
Clearly, perceiving pre-performance anxiety as a normal and helpful aspect of performing
83
Ibid.
84
Kendrick, 20.
85
Parncutt and McPherson, 53.
37
can be an important cognitive strategy. 86
3.5 RELAXATION TECHNIQUES
In an attempt to improve upon the standard cognitive-behavioral treatment for
musicians with performance anxiety, Roland (1994a) developed some modifications. He
compared two treatment groups with a wait-list control group. The standard cognitivebehavioral treatment incorporated relaxation techniques (breathing awareness,
progressive muscle relaxation, and mental suggestions and imagery to produce a relaxed
state) and cognitive techniques (normalizing the experience of anxiety and developing
positive self-talk). The modified cognitive-behavioral treatment group incorporated the
same relaxation techniques, normalizing the experience of anxiety but without training in
positive self-talk. It also included training in task-oriented thinking, setting performance
goals, mental rehearsal, and developing a pre-performance routine. The training sessions
were conducted over four two-hour weekly sessions. The modified treatment showed no
superiority over the standard procedure. 87
Specific thoughts may become associated with specific behaviors, so that the
occurrence of either tends to bring on the other. 88 Thoughts also occur in performance
86
Ibid.
87
Ibid., 54.
88
Paul G. Salmon and Robert G. Meyer. Notes from the Green Room: Coping with Stress and
Anxiety in Musical Performance (New York: Lexington Books, 1992), 155. For example, one musician
found that whenever he began to play a piece of music onstage or practicing, he was distracted by the
thought that he would forget what he was playing at some point. It seemed that the act of beginning to play
inevitably caused him to worry about a memory slip. Furthermore, he felt anxiously compelled to seek out
an instrument to play in order to reassure himself that he could remember the music. These two
experiences - one of playing, the other of worrying - became so closely and unpleasantly associated that he
began to cut back on practicing to avoid worrying about having a memory slip. The association between
worrying about his memory and playing in turn triggered other maladaptive thoughts. He began to criticize
himself for having such thoughts, feeling worried that the prediction would come true but angry at himself
because of his inability to control his thinking. To fight this problem, he used a technique called “thought
stopping,” in which he verbalized the command “stop” as soon as he became aware of worrisome thoughts
38
situations when they become part of an automatic sequence of anxiety-provoking events
that often occur before a performing event. This sequence often has a spiraling effect, in
which anxious thoughts trigger defensive behaviors, which heighten apprehension,
increase vigilance, and promote even more worry. 89 This gradually increasing cycle of
anxiety - a mixture of thoughts, feelings, and behaviors - may be smoothly integrated so
that a person is hardly aware of the incremental pressure. A performer may experience
hand and leg tremors, for example, whenever anxiety develops. At times, the shaking
could become so pronounced that it would cause restriking of the keys unintentionally
and, in general, result in a loss of muscle control. The performer would have likely dealt
with this for several years, grown to anticipate it, and worried that the shaking would
become so debilitating that the performance would have to stop. This individual could
get help from a therapist who would uncover the cycle of thoughts and behaviors that
cause the tremors to intensify. The therapist would teach the individual how anxiety
gradually increases before a performance and help to develop relaxation and
concentration-focusing responses that could be applied at successive stages. The
musician would then practice a simple quieting response (closing the eyes, taking a deep
while playing. Drawing conscious attention to the concept gave him a measure of control and prevented
this thought from dominating his awareness as it previously had done. Second, he learned to inhibit the
anxious urge to practice compulsively whenever he was struck by a troubling thought. In its place, he
developed a structured schedule that was regulated by the clock rather than by anxious cognitions. In
addition, he learned a simple relaxation technique that helped dissipate the tension caused by his thoughts
and that provided a useful alternative to compulsive practicing. Finally, he learned and practiced a series of
“self-statements” that constituted a rational way of addressing the underlying problem. In response to fears
of a memory lapse, he learned to do two things. First, he tried to focus his response to a specific issue, such
as a troublesome measure in a piece. Second, he reassured himself that he would work especially hard on
this problem area during his next practice session. By using all of these techniques, he was able to
dissociate the fearful thought from his adaptive impulse to practice, which he otherwise enjoyed. The
anxiety previously evoked by the obsessive thought was gradually replaced by self-assurance as the thought
became linked with the positive feelings resulting from a good practice session.
89
Ibid.
39
breath, relaxing the muscles, and visualizing a calming image or word) whenever
spiraling anxiety was triggered. 90
Although some physiological effects from anxiety can be detrimental during a
performance, thoughts can also affect a performance negatively because performers may
think about performing in stress-provoking ways that are illogical. Anxiety is generally
accompanied by a tendency to interpret minor problems as major catastrophes and to
anticipate danger where none exists. For example, musicians may think their way into a
state of anxiety by focusing on mistakes in a piece being prepared for a recital and
conclude that they will never be able to perform it well. There are two errors in
reasoning in this statement. The first is that mistakes are not necessarily predictive of a
bad performance, and consequently, the performer draws a conclusion based on
insufficient or overly selective evidence. The second is the assertion of never being able
to play the piece properly. This involves the use of a definitive word like “never,” which
offers little hope for change and is an example of “absolute thinking,” skewing a
performer’s focus. 91
One of the most troublesome effects of anxiety is that it can cause a person to lose
perspective. When anxiety ensues, there is a feeling that the world is closing in and
attention becomes riveted on a small number of things. When performing, for example,
attention may be captured by trembling knees or a pounding heart. At such times, it is
difficult to remain calm and maintain perspective but important to do so. An individual
may feel that everyone in the audience is acutely aware of his or her discomfort and very
90
Ibid., 156.
91
Ibid.
40
critical of him or her. Anxiety brings certain elements into focus, but prevents a person
from seeing the broader picture. One way psychologists attempt to control aversive
thinking during a performance is to reframe and reinterpret an experience in ways
previously not considered. One good example is the way a person thinks about anxiety.
Because anxiety is negative, a sign of psychological vulnerability or even pathology, it
causes shame or embarrassment, and for others it highlights their inability to be
performers. By giving performers a new perspective, their performance is improved.
3.6 FLOODING
The technique of flooding appears to have proven most successful under live
circumstances and is just the opposite of systematic desensitization. Instead of
visualizing scenes of adversity in a hierarchical arrangement while remaining calm and
comfortable, the subject is asked to visualize or experience anxiety-inducing stimuli
under live circumstances and “sustain the full thrust of the attendant anxiety over a
protracted period of time.” 92 In this case, the length of exposure is the critical
determinant (up to two to three hours for each session). If exposure to the dreaded
stimuli is too short, the effect will be to reinforce it (an effect called “incubation”);
however, past a certain point, anxiety begins to subside and is eventually extinguished. 93
3.7 IMPLOSION THERAPY
A related, but more psychodynamic approach to flooding is implosion therapy.
The fundamental difference is that, instead of utilizing actual live circumstances,
experiences, or visualizations that have emerged from interviews with the subject, the
92
Reubart, 186.
93
Ibid.
41
therapist contrives exaggerated rather than realistic scenes that he believes have been
associated with the anxiety-stimulus but repressed, therefore becoming part of the
unconscious. The subject is asked to visualize these catastrophic scenes as vividly as
possible, over a protracted period, feeling all of the attendant emotion that they induce.
Extinction occurs after a number of repetitions of such exposure. 94
PART II: PHARMACOLOGICAL TREATMENTS:
All of the treatments discussed in the following section are for information only
and do not serve as an endorsement of any information contained herein. Interested
persons should consult with a physician or psychologist prior to beginning a treatment.
3.8 BENZODIAZEPINES
Benzodiazepines have been the most widely used treatment for generalized
anxiety over the last three decades of the twentieth century, having almost completely
replaced barbiturates and meprobamate. The majority of controlled comparisons have
demonstrated greater anxiolytic efficacy of benzodiazepines than barbiturates, and to a
lesser extent meprobamate (Shader and Greenblatt, 1974). 95 However, the major
advantages of benzodiazepines are their much greater margin of safety, their ability to
control anxiety without excessive sedation, and their generally milder withdrawal effects.
Variability of benzodiazepine response is due both to methodological differences and to
the heterogeneity of patients treated for GAD. Benzodiazepines enhance the effect of
the neurotransmitter gamma-aminobutyric acid, which results in sedative, anxiolytic
94
Ibid., 187.
95
Benjamin B. Wolman and George Stricker, Anxiety and Related Disorders: A Handbook (New
York: John Wiley and Sons, Inc., 1994), 318.
42
action. These properties make benzodiazepines useful in treating anxiety.
Benzodiazepines are categorized as either short-, intermediate- or long-acting. Longeracting benzodiazepines are recommended for the treatment of anxiety. A great many
nonpharmacologic factors have been found to affect a patient’s acute response to
benzodiazepines (Rickels 1978). 96 Better response has been found in women, those who
are employed, those who have higher socioeconomic status, those who see their problems
as emotional (rather than due to a physical disease), and those who expect medication to
help them. Patients with severe anxiety, especially if it is of acute duration; those without
concurrent physical illness; and those who have responded well to prior anxiolytic
treatment tend to respond best. Physician’s warmth and optimism about the treatment
have been found to enhance both medication and placebo responses (Rickels 1970), while
ongoing unfavorable life events during treatment diminish response. 97
Parameters of dosing and response vary widely among patients. Published studies
have generally used the equivalent of 10 to 40 mg diazepam daily. Marked response can
often be seen during the first week of treatment, and may even occur within a few days.
Many clinicians have been reluctant to prescribe benzodiazepines chronically for fear that
patients would habituate to the therapeutic effects, require escalating doses, remain tied to
the medication due to withdrawal symptoms, or even develop addictive behaviors that did
not exist previously. While transient withdrawal syndromes on cessation of
benzodiazepines are common, Rickels and colleagues (1983) found that patients taking
such medications for longer than eight months were more likely to experience clinically
96
Ibid., 319.
97
Ibid.
43
significant withdrawals. 98
The following is a list of prescription benzodiazepines:
1. Alprazolam (Xanax)
2. Chlordiazepoxide (Librium)
3. Clonazepam (Klonopin)
4. Diazepam (Valium)
5. Lorazepam (Ativan)
3.9 BETA-ADRENERGIC
In the past decade, growing concern over the dependence potential of
benzodiazepines has intensified the search for alternatives. Beta-adrenergic blockers,
also known as beta blockers, which act specifically to inhibit peripheral autonomic
symptoms, are promising in that they supposedly leave the head clear while at the same
time eliminating problems such as tremor and butterflies. 99 The beta-blocking drugs
appear to have certain advantages over the benzodiazepines; mainly that they lack
addictive potential, are not sedating, and are free of cognitive impairment at anti-anxiety
doses (Turner, 1977). Unfortunately, they appear to be less effective than
benzodiazepines, and this more than offsets their advantages in terms of safety. Evidence
is mixed as to whether they improve musical performance as judged by the outside
observer. In any case, they seem less than ideal because of possible side effects such as
loss of sexual potency, nausea, tiredness, and dulling of affect. In asthmatics the blockers
are particularly dangerous and occasionally precipitate heart failure. Although many
98
Ibid., 320.
99
Last and Hersen, 445.
44
musicians take them regularly, in the United States and some other countries, their use for
performance anxiety is not sanctioned by medical authorities. They may be helpful in
breaking strongly conditioned anxiety cycles and getting performers back onstage when
they have been frightened off, but psychological procedures aimed at restoring selfcontrol to the performer would seem preferable, because performers are then relying on
their own resources. 100
The following is the only prescription form of beta-adrenergic:
1. Beta-blockers (Propranolol, Practolol, Sotalol)
3.10 BUSPIRONE
Buspirone has gained clinical interest because of its very different side effect
profile from benzodiazepine anxiolytics. It does not tend to cause fatigue or sedation,
does not interfere with psychomotor performance, and does not produce a withdrawal
syndrome when abruptly withdrawn. Most trials have consistently demonstrated its
superiority to placebo, and overall equivalence to benzodiazepines. 101 It is not known
exactly how this medicine works to relieve anxiety. It is believed that it may react with
specific chemical receptors in the brain.
The following is the only prescription form of buspirone:
1. Buspar
3.11 TRICYCLIC ANTIDEPRESSANTS
Tricyclic antidepressants (TCA’s) have been used in clinical practice for nearly
50 years. The term tricyclic refers to the basic three-ring chemical structure of these
100
Parncutt and McPherson, 51.
101
Wolman and Stricker, 321.
45
compounds; it also serves as a type of short-hand to separate TCA’s from a distinctly
different group of drugs with anti-anxiety and anti-depressant properties known as
monoamine oxidase inhibitors (MAOI’s). 102 The TCA’s evolved from a larger family of
tricyclic drugs (phenothiazines), which play a central role in treatment of psychotic states.
Tricyclics differ from phenothiazines in that a sulfer atom in the center ring has been
replaced by an ethylene bridge. This substitution results in a major change in how the
TCA drug appears in three-dimensional space, hence altering its affinity for various
neurochemical receptor sites. Tricyclics, thus, do not have clinically significant
antipsychotic effects. 103 The main side effect of concern is to the cardiovascular system,
therefore patients with heart conditions are advised not to take tricyclic antidepressants.
Most recently, amitriptyline, desipramine, and imipramine have shown increasing
advantages over benzodiazepines the longer the patient takes the drug (after four
weeks). 104
The following is a list of prescription tricyclic antidepressants:
1. Amitriptyline (Amitril)
2. Clomipramine (Anafranil)
3. Imipramine (Tofranil)
4. Trimipramine (Surmontil)
102
Last and Hersen, 460.
103
Ibid., 461.
104
Wolman and Stricker, 320-321.
46
3.12 SELECTIVE SEROTONIN REUPTAKE INHIBITORS
Prior to the selective serotonin reuptake inhibitors (SSRIs), most of psychotropic
medications were the result of chance observation. Tricyclic antidepressants were
discovered by chance. The TCAs were the result of an unsuccessful attempt to improve
on the antipsychotic effectiveness of phenothiazines (medication used in the treatment of
schizophrenia). Molecular modifications of phenothiazines led to synthesis of
imipramine, the first clinically useful tricyclic antidepressant.105
Older chance-discovery drugs have many clinical effects either because they
affect a site of action with broad implications for organ function or because they affect
multiple sites of actions. Chance-discovery drugs typically will produce a number of
undesired, as well as desired, effects and will have a narrower therapeutic index in
comparison with a drug that was rationally developed to affect only the site of action
necessary to produce the desired response.
The SSRIs were developed in response to the need for better tolerated, safer
antidepressants than the TCAs, but no less effective for the symptoms of depression. The
first SSRI, fluoxetine (Prozac) was released in 1987. Each of the SSRIs was the product
of a development strategy in which the goal was to produce a drug capable of inhibiting
the reuptake of serotonin, but without affecting the various other neuroreceptors (ie,
histamine, acetylcholine, and alpha1-adrenergic receptors), affected by the TCAs. The
development of the SSRIs, with their selective mode of action, has resulted in a class of
antidepressant drugs possessing an improved side-effect profile, while retaining good
105
Mayo Clinic, “Selective Serotonin Reuptake Inhibitors (SSRIs),”
www.mayoclinic.com/health/ssris, 2010.
47
clinical effectiveness. 106
SSRIs affect the chemicals that nerves in the brain use to send messages to one
another. These chemical messengers, called neurotransmitters, are released by one nerve
and taken up by other nerves. Neurotransmitters that are not taken up by other nerves are
taken up by the same nerves that released them. This process is termed "reuptake."
SSRIs work by inhibiting the reuptake of serotonin, an action which allows more
serotonin to be available to be taken up by other nerves. 107 SSRIs are the most widely
prescribed antidepressants today because they have the least amount of side effects and
are not addictive.
The following is a partial list of prescription SSRIs:
1. Duloxetine (Cymbalta)
2. Escitalopram (Lexapro)
3. Fluoxetine (Prozac)
4. Paroxetine (Paxil)
5. Venlafaxine (Effexor)
PART III: ALTERNATIVE TREATMENTS
All of the treatments discussed in the following section are for information only
and do not serve as an endorsement of any information contained herein. Interested
persons should consult with a physician or psychologist prior to beginning a treatment.
For musicians with restrictions to cognitive-behavioral therapy and/or
106
Wolman and Stricker, 332-335.
107
Ibid, 335.
48
pharmacological treatments, alternative treatments may be useful. Mind-body
techniques, nutrition, exercise, and herbs may help reduce performance anxiety.
Progressive muscle relaxation, diaphragmatic breathing, biofeedback, meditation, and
self-hypnosis can help relaxation and reducing anxiety before and during a
performance. 108
3.13 EXERCISE
Physical exercise is one of the most powerful and effective methods for
preventing and reducing anxiety. 109 Exercise raises the level of serotonin in the brain and
increases the activity of serotonin in the cerebral cortex. Serotonin is a neurotransmitter,
one of the chemicals in your brain that facilitates transmission of nerve signals.
Increased serotonin is associated with amelioration of all of the anxiety disorders. 110
Exercise also counters several of the physiological factors that underlie anxiety,
which is why individuals who exercise regularly tend to have less frequent and milder
episodes of anxiety.
Exercise brings about:
•
Reduced skeletal muscle tension, which is largely responsible for feelings of
being tense
•
More rapid metabolism of excess adrenaline and thyroxin in the bloodstream (the
presence of these hormones tends to sustain a state of arousal and vigilance)
•
Enhanced oxygenation of the blood and brain, which increases alertness and
108
Ibid., 2.
109
Bourne, Edmund J, Natural Relief for Anxiety (Oakland, CA: New Harbinger Publications, Inc.
2004), 32-33.
110
Ibid.
49
concentration
•
Stimulation of the production of endorphins, natural substances in the brain that
resemble morphine both chemically and in their effects, increasing a sense of
well-being
Furthermore, yoga poses provide effective relief of anxiety by relaxing tense muscles and
oxygenating the entire body, which has a calming effect on mood. 111
3.14 NUTRITION
The requirements for a nutritionist are at least a bachelor's degree and a licensure,
certification, or registration by the state. Each state will vary according to the minimum
requirements. Although there is no diet to relieve anxiety, eating healthy meals helps to
maintain a well-nourished and strong body. If a musician struggles with performance
anxiety, avoiding caffeine, alcohol and nicotine may diminish restlessness enhanced by
such substances. If the body’s blood sugar level lowers significantly, muscle control and
cognitive functioning may be impaired. To avoid this issue, a performer should eat
frequent small meals that contain protein, complex carbohydrates (fresh vegetables,
whole grains, and fruits), and healthy fats before a performance. 112
3.15 HERBS
Herbalists and herbs are not regulated by the Food and Drug Administration,
therefore an individual must take caution when using these products. The use of herbs is
a time-honored approach to strengthening the body and treating disease. Herbs, however,
can trigger side effects and interact with other herbs, supplements, or medications. For
111
Gottlieb, Bill, Alternative Cures (Rodale, 2000), 35-36.
112
Bourne, 55-56.
50
these reasons, take herbs only under the supervision of a health care provider. The
following herbal treatments may improve performance anxiety as an alternative to
aforementioned prescription options.
1. Valerian (Valeriana officinalis, 150 mg 2 - 3 times per day) is an
herbal treatment for insomnia that is sometimes used to treat anxiety as
well, although evidence is mixed. Some studies show that valerian
does help reduce anxiety, but one study found that valerian was no
better at reducing social anxiety than placebo. Valerian is often
combined with lemon balm (Melissa officinalis) or with St. John's
Wort (Hypericum perforatum) for treating mild-to-moderate anxiety.
Valerian may interact with other drugs that have a sedative effect, such
as benzodiazepines, barbiturates, narcotics, antidepressants, and
antihistamines.
2. Passionflower (Passiflora incarnata) -- passionflower is a natural
tranquilizer as effective as valerian and some of the benzodiazepines in
relieving anxiety. It both relieves nervous tension and relaxes
muscles. It is available in either capsules or liquid extract at health
food stores. 113 The same precautions that apply to valerian apply to
passionflower.
3. Kava kava (Piper methysticum, 100 - 200 mg 2 - 4 times a day) is a
South Pacific herbal drink prepared from the kava root, kavalactones,
which produces a tranquilizing effect. It is useful for mild-to-
113
Bourne, 131-132.
51
moderate anxiety. Small doses produce a sense of well-being, while
large doses can produce lethargy, drowsiness, and reduced muscle
tension. Research has shown that kava diminishes the limbic system,
particularly the amygdala, which is a brain center closely associated
with anxiety. 114 More specifically, kava appears to enhance the effects
of the neurotransmitter GABA in the amygdala and other structures of
the brain such as the hippocampus and medulla oblongata. The Food
and Drug Administration (FDA) has issued a warning concerning
kava's effect on the liver. In rare cases, severe liver damage has been
reported. 115
4. Other herbs sometimes suggested for anxiety include ginger (Zingiber
officinalis), chamomile (Matricaria chamomilla), and licorice
(Glycyrrhiza glabra). Licorice should be avoided if there is heart
failure, heart disease, kidney or liver disease, or high blood pressure.
Licorice may interfere with diuretics (water pills), anticoagulants
(blood thinners), or antidepressants such as Prozac. 116
Essential oils of lemon balm, bergamot, and jasmine are calming, and may be
used as aromatherapy. Place several drops in a warm bath or atomizer, or on a cotton
ball.
114
Ibid., 127.
115
Michael Murray and Joseph Pizzorno, Encyclopedia of Natural Medicine, 2nd ed. (New York:
Three Rivers Press, 1998), 255-257.
52
3.16 HOMEOPATHY
Although few studies have examined the effectiveness of specific homeopathic
therapies, professional homeopaths may consider the following remedies for the
treatment of anxiety based on their knowledge and experience. There are no current
regulations for homeopaths, so take caution when using these products. Before
prescribing a remedy, homeopaths take into account a person's constitutional type -- the
physical, emotional, and psychological makeup. An experienced homeopath assesses all
of these factors when determining the most appropriate treatment for each individual.
1. Aconitum – serum from an herbaceous perennial toxic plant used for
anxiety; accompanied by irregular or forceful heartbeat, shortness of
breath, or fear of death.
2. Arsenicum album -- is a frequently-used homeopathic substance
derived from the metallic element arsenic. For homeopathic use,
arsenicum album is prepared by separating arsenic from iron (as in
arsenopyrite), cobalt, or nickel by baking at high temperatures. The
powder is then ground and diluted with lactose. In the final dilution,
there are normally no atoms of arsenic left. The final product is sold as
tinctures (liquid), tablets, pellets, or powder. Arsenicum album is one
of the fifteen most important remedies in homeopathy. It is used for
excessive anxiety that has no clear cause and is accompanied by
restlessness, especially after midnight. It also may be used for
perfectionists, including children, who worry about everything.
116
Bourne, 128.
53
3. Phosphorus — a chemical element of the nitrogen group, phosphorus
is commonly found in inorganic phosphate rocks. It is used for an
impending sense of doom and anxiety when alone. It also may be used
for impressionable adults and children who are easily influenced by
the anxiety of others.
4. Lycopodium-- also known as ground pines or creeping cedar. It is
used for performance and other types of anxiety in those who are
insecure yet hide their low self-esteem with arrogance and bravado. It
also may treat children with anxiety accompanied by bedwetting.
5. Gelsemium-- is composed of the dried rhizome and root of Gelsemium
nitidum (Michaux), a climbing plant growing in the southern States of
North America and there known as Yellow Jasmine. It is used for
performance anxiety resulting in diarrhea, headache, dizziness,
weakness, shakiness and trembling, or trouble speaking. Gelsemium is
a climbing, woody evergreen vine characterized by very fragrant,
bright yellow flowers. There are no recent clinical studies of
gelsemium to provide a basis for dosage recommendations. Classical
use of this herb indicated 30 mg of the rhizome. Current use is
primarily homeopathic. Documented adverse effects in pregnant or
lactating women.
6. Argentum nitricum—silver nitrate, a micro-nutritional mineral
preparation. It is used for performance anxiety (such as before tests in
school-age children) with rapid heart rate, feeling of faintness,
54
diarrhea, or flatulence. 117
3.17 ACUPUNCTURE
The American Board of Medical Acupuncture (ABMA) was established in 2000
to promote safe, ethical, efficacious medical acupuncture to the public by maintaining
high standards for the examination and certification of physician acupuncturists as
medical specialists. 118 Some evidence shows that acupuncture may help reduce
symptoms of anxiety, especially when combined with behavioral therapies (including
psychotherapy). One study showed that benefits lasted as long as one year after
treatment. Acupuncturists treat people with anxiety based on an individualized
assessment of the excesses and deficiencies of qi (pronounced “chee”) located in various
meridians. With anxiety, a qi deficiency (qi is the term used in traditional Chinese
medicine to describe your body’s energy) is often detected in the kidney or spleen
meridians. 119 In addition to performing needling techniques, acupuncturists may also use
lifestyle and breathing techniques as well as herbal and dietary therapy.
3.18 MEDITATION
Meditation is a process of distancing oneself from emotional and psychological
attachments that seem to compose an identity and ultimately connecting to a deeper, more
fundamental self. An individual becomes still and quiet enough to reconnect with the
deeper inner self. This allows a person to relinquish value judgements and achieve a
better perspective on thoughts, emotions, and desires that continuously cycle through the
117
University of Maryland Medical Center, “Anxiety,”
http://www.umm.edu/altmed/articles/anxiety-000013.html (accessed February 2, 2010).
118
http://dabma.org (accessed on October 28, 2010).
119
Bourne, 167.
55
mind and body. 120 Meditation practice is based, in part, on the belief that automatic
thoughts and emotional reactions to them are the source of all human suffering. Since
ancient times, meditation has been used as a means of transcending suffering and
acquiring a healthy distance between self and thoughts. It is a process of viewing
thoughts from a distance without reacting to them.
PART IV: TREATMENT FACILITIES
All of the treatments facilities discussed in the following section are for
information only and do not serve as an endorsement of any information contained
herein. Interested persons should consult with a physician or psychologist prior to
beginning a treatment.
An individual experiencing moderate to severe anxiety may need to seek help
from a treatment center specializing in anxiety therapy. Listed below are the types of
people and places that will make a referral to, or provide, diagnostic and treatment
services:
•
Family doctors
•
Mental health specialists, such as psychiatrists, psychologists, social workers, or
mental health counselors
•
Religious leaders/counselors
•
Health maintenance organizations
•
Community mental health centers
•
Hospital psychiatry departments and outpatient clinics
•
University- or medical school-affiliated programs
120
Bourne, 143-144.
56
•
State hospital outpatient clinics
•
Social service agencies
•
Private clinics and facilities
•
Employee assistance programs
•
Local medical and/or psychiatric societies
3.19 OUTPATIENT THERAPY PROGRAMS
Outpatient therapy is a partnership between an individual and a professional, such
as a psychologist, who is licensed and trained to help people understand their feelings and
assist them with changing their behavior. Research suggests that therapy effectively
decreases patients' anxiety and related symptoms- such as pain, fatigue and nausea.
Research increasingly supports the idea that emotional and physical health are closely
linked and that therapy can improve a person's overall health status. There is convincing
evidence that most people who have several sessions of therapy are more greatly
improved than untreated individuals with emotional difficulties. One major study
showed that 50 percent of patients noticeably improved after eight sessions while 75
percent of individuals in therapy improved by the end of six months. 121
PALMETTO HEALTH
Adult Psychiatric Treatment - The following information is promoted by Palmetto
Health (www.palmettohealth.org). 122 All narrative included here is directly from this
website.
Individuals will find the support they need in our Day Treatment Programs. These
121
www.apa.org (accessed on October 3, 2010).
122
www.palmettohealth.org (accessed on October 2, 2010).
57
programs may also be helpful for patients as they integrate back into their home after an
inpatient stay. The Day Treatment Program offers a full or half-day of intensive
treatment, and patients return home to their families at the end of the day. They have the
benefit of immediately integrating the coping skills they have learned into their daily
lives. This program is offered at Palmetto Health Baptist and Richland Springs.
Patients in this program are seen each day individually by a psychiatrist for
medication management. Other treatment includes individual and group therapy
promoting coping skills and a balanced lifestyle. Sometimes families are included in
therapy sessions to discuss stressors or issues affecting the patient.
YALE ANXIETY AND MOOD SERVICES
The following information is promoted by Yale Anxiety and Mood Services,
affiliated with the psychology department at Yale University (www.yale.edu/yams). 123
All narrative included here is directly from this website.
Do you find yourself constantly worrying about lots of different things? Do you
find it difficult to stop worrying? Do you have difficulty relaxing, sleeping, and enjoying
the moment? Everybody worries to some degree. We live in a very uncertain world -politically, economically, as well as emotionally. However, when worry starts to become
pervasive and negatively impacts your life, you may benefit from professional help.
Pervasive worry and anxiety can affect your health, your ability to perform your
best at work and home, develop meaningful relationships, and feel good about yourself.
Your worries may be accompanied by uncomfortable physical symptoms such as
trembling, muscle tension, headaches, irritability, sweating, feeling lightheaded and out
123
www.yale.edu/yams (accessed on October 3, 2010).
58
of breath, nauseous and/or hot flashes. You may have trouble sleeping and concentrating
and may feel hopeless and helpless about your situation.
Other people may tell you to "just stop" worrying, however, it's not that easy.
Worry is a universal human experience; however, when worry does not stimulate
learning and insight, it may lead to feelings of helplessness that are very hard to "snap out
of." Our clinicians will work with you to examine and address your physical symptoms,
underlying beliefs that sustain your worries, fears of uncertainty, interpersonal issues, and
practical problem-solving.
ANXIETY AND AGORAPHOBIA TREATMENT CENTER
The following information is promoted by Dr. Karen Cassiday (she has been
featured on the Today Show, CNN Headline News and Nightline), leader of the Anxiety
and Agoraphobia Treatment Center (www.anxietytreamentcenter.com). 124 All narrative
included here is directly from this website.
Generalized anxiety disorder occurs in approximately 3.1% of the adult population
and in 3% of children and adolescents. It occurs almost twice as often in females as
males. Those who suffer from generalized anxiety disorder experience chronic worry and
chronic symptoms of anxious arousal, such as muscle aches, insomnia, headaches,
stomachaches, feeling tired or mildly ill or feeling chronically restless and irritable. GAD
frequently co-occurs with other mental health disorders. Often those who worry believe
that their worry, though bothersome, may have some value in protecting their own safety,
or the safety of others, or in maintaining high standards or schoolwork or job
performance. Reassurance seeking is often a problem with those who have GAD.
59
Conversations about worry will revolve around seeking the reassuring opinions other
others over and over but with no apparent end to the worry. Friends and spouses
frequently feel that they are being hounded by the reassurance seeking behaviors of those
who have GAD.
Successful treatment of GAD includes cognitive therapy to learn to tolerate
uncertainty, effectively solve problems and decrease perfectionism. Exposure therapy and
imaginal flooding helps learn to no longer dread the future. If chronic physical arousal
makes it impossible for a patient to relax, then relaxation training and mindfulness
training will be taught to help restore the body’s normal resting state. Referral for
medication may be necessary when depression or other disorders make it difficult to
engage in treatment for worry.
Staff at AATC have specialized experience in helping patients learn to stop and
escape the endless cycle of worry and reassurance seeking. Our goal is to help worriers
learn to live in the present so that they can relax and enjoy their daily lives. Our goal is to
help you learn to live with the uncertainty and risk taking that is a normal part of life.
3.20 INPATIENT THERAPY CENTER
Inpatient therapy is designed for patients requiring 24-hour care based on specific
criteria: if anxiety has permeated the daily routine whereas an individual cannot function
in his/her duties; he/she is a threat to himself/herself and/or a threat to society. 125 Consult
your physician and/or psychologist for referrals.
124
125
www.anxietytreatmentcenter.com (accessed October 4, 2010).
www.apa.org (accessed on October 21, 2010).
60
PALMETTO HEALTH
The following information is promoted by Palmetto Health Inpatient Program
(www.palmettohealth.org). 126 All narrative included here is directly from this website.
In any given year, nearly 1 in 5 adults suffers from a diagnosable mental illness.
Some people may be affected mildly, but some people may be affected more severely,
with symptoms that become debilitating. We can help.
At Palmetto Health Behavioral Care we offer inpatient care for individuals
needing 24-hour supervision and treatment. We provide treatment for individuals with a
wide range of diagnoses including, but not limited to:
1. Depression
2. Anxiety Disorders
3. Bipolar Disorder
4. Psychotic Disorders
There are two inpatient units available at both Richland Springs and Palmetto
Health Baptist to treat adult patients with psychiatric illnesses: The Affective Disorders
Units offer programs for those with mood disorders such as depression or anxiety. The
Crisis Stabilization Units offers the highest level of management for patients with the
most severe mental illnesses, some who are experiencing symptoms for the first time and
others who many have struggled with their illness for years. Treatment is led by a
psychiatrist, and in conjunction with psychologists, nurses, counselors, and social
workers they develop an individualized treatment plan for each patient. Treatment
includes:
1. One-on-one sessions with the psychiatrist and other therapists
61
2. Group therapy
3. Art therapy
4. Activity therapy
5. Neuropsychological testing may be used to assist the psychiatrist in
making a diagnosis or to assess a patient’s level of functioning
126
www.palmettohealth.org (accessed on October 2, 2010).
62
CHAPTER IV
CONCLUSION
Performance anxiety has plagued many musicians throughout time and inhibits a
performer’s potential. Sigmund Freud launched the discussion of “neurotic anxiety”
through psychoanalysis which paved the way for current cognitive-behavioral
psychology. Freud’s neurotic anxiety corresponds with performance anxiety in that the
musician misconstrues inner feelings about performing in an exaggerated way, for
example, as threatening. As influential as Freud was during his lifetime and beyond, his
founding of psychoanalysis was a stepping stone for cognitive-behavioral psychology,
which is an effective therapy for performance anxiety.
The current analysis of anxiety is two-fold, irrational thought processes and a
limiting of basic cognitive skills. A musician can be afflicted from previous negative
performing experiences and create an illogical thought process for future performing
events. Undesirable feelings can overtake an individual and create a sense of doom about
performing. The other aspect of anxiety is the limiting of performing skills, such as
agility, focus, and memory. A pianist may have a memory lapse during a performance
and not be able to continue the music.
There are seven main psychological techniques a therapist may use to treat
performance anxiety. These cognitive-behavioral therapies consist of systematic
desensitization, attention training, behavior rehearsal, stress inoculation, relaxation
63
techniques, flooding and implosion therapy. Systematic desensitization, relaxation
techniques and flooding are the most widely used by psychologists. Systematic
desensitization consists of the therapist gradually increasing the intensity of the anxietycausing scenario to the patient week by week. Over time, the goal is to experience less
anxiety each time the individual is exposed to the stressful events. This allows the patient
to build coping skills when placed in a performance medium and the behavior is
positively changed. In conjunction with systematic desensitization, relaxation techniques
offer a performer basic tools to manage the anxiety.
Some of these techniques include deep breathing, constricting and releasing
muscles and visualizing a calming image. After these steps have been taken, an
individual will feel more confident to perform because there is now control over the body
and focus. Relaxation techniques are beneficial and effective for controlling performance
anxiety. In addition to relaxation, flooding can be a useful method when used properly.
Flooding starts with feeling the full thrust of the anxious event followed by
subsequent diminishing levels of exposure. This method is beneficial because confidence
is built through enduring a difficult situation and feeling less anxious the next time a
patient is exposed. As long as the patient has positive coping skills, flooding can be
effective. Otherwise, an individual may be more traumatized and the therapy may take
even longer. If an individual needs further treatment, there are anxiety treatment centers
nationwide that can provide a more intensive therapy environment. While psychological
therapy is beneficial and needed to overcome anxiety, there are pharmacological
treatments available to combine with cognitive-behavioral therapies that provide a more
effective management of performance anxiety.
64
There are five categories of anti-anxiety drugs: benzodiazepines, beta-adrenergic,
buspirone, tricyclic antidepressants, and selective serotonin reuptake inhibitors (SSRI).
These inhibit the reuptake of serotonin by neurotransmitters, thus allowing more
serotonin to flow in the body, which gives a sense of well-being. Some of the SSRI’s
prescribed are Prozac, Lexapro and Zoloft. SSRI’s are the newest and most widely
prescribed anxiolytic drugs today because of their non-habit forming function and having
the least amount of side effects of all anti-anxiety drugs. While pharmacological
treatments are effective for many people, they may not be considered for some. In that
case, there are alternative treatments for performance anxiety.
Homeopathy provides several treatment options for anxious persons, such as
botanical supplements, acupuncture and meditation. Most of the botanical treatments are
safe, as long as they are used as directed, and give a sedating effect. One of the most
widely used supplements is Kava. Kava is a South Pacific herbal drink prepared from the
kava root, kavalactones, which produces a tranquilizing effect. Acupuncture can stress a
specific site on the body and then produce a calming effect when released. Finally,
meditation allows an individual to center his focus of attention and remove excess
negative energy.
Inpatient and outpatient therapy centers are focused mainly on cognitivebehavioral therapy to treat a person suffering from GAD. A sampling of outpatient
therapy centers are listed in chapter three and in the appendices to provide examples of
appropriate places for therapy. One inpatient center is listed in chapter three to provide
an example of an appropriate place to use if the anxiety reaches an extreme measure one
cannot function in his/her daily life.
65
The goal of this paper is to shed light on the unwanted problem of performance
anxiety and the ways in which to treat it. Piano instructors, concert pianists, and
musicians alike will find help for themselves or their students to alleviate performance
anxiety by following the steps discussed in this dissertation. There is hope for a more
enjoyable performing experience in the future.
66
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APPENDIX A
The following list entails treatment facilities in South Carolina that are accredited by
the American Psychological Association (APA) (www.apa.org). 127 All narrative
included here is directly from the APA listings. Interested parties may search the website
for programs in their area.
1. Comprehensive Health and Family Services
5711 North Main St., Main Office
Columbia, SC 29203
Phone Number: (803) 572-4172
Objectives for children and their families are to promote the public primary care
provision of behavioral health, mental health and other services within the context of a
system of care that weaves health, mental health and other supports into a coordinated
fabric of services to meet the diverse, highly individual, and changing health, educational,
and supportive needs of children, adolescents, and adults with severe emotional
disturbance and untreated health conditions due to the lack of income.
2. Assessment and Counseling Services
1 Harbison Way, Suite 110
Columbia, SC 29212
Phone Number: (803) 781-4265
127
www.apa.org (accessed on October 13, 2010).
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Assessment and Counseling Services has a general psychotherapy practice
treating children, adolescents and adults. This facility has been in private practice since
1988 and specializes in Cognitive Behavioral Therapy (CBT) and Behavioral Family
Psychotherapy. We offer a compassionate, yet firm, approach which has helped
thousands of patients lead more happy and productive lives. We provide clear, precise
feedback and instructions on how to correct their problems. Most patients choose to
audiotape their sessions so they can listen to the sessions again at home and take notes.
Skills are developed by completing exercises between sessions. This practice does not
believe in endless therapy that costs you a fortune. Our educational and skills building
approach teaches patients the skills they need so they quickly no longer need
psychotherapy.
3. LifeCare Psychology Group, LLC
800 East Cheves Street, Suite 390
Florence, SC 29506
Phone Number: (843) 667-4949
The goal at LifeCare is to integrate the benefits of professional psychology with the
eternal characteristics, beliefs and practices of the Christian faith for the provision of
psychotheological therapies. It is our belief that this synthesis will provide the best
possible care of body, mind and spirit for those individuals who are believers in the
Christian faith or who are searching spiritually in adoptive consideration of Christianity.
Individuals of different faiths, or those who have not adopted a personal religion, will be
respected in all ways and in these circumstances traditional psychotherapies will be
utilized with the same intent of providing the best care possible.
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4. Seasons Psychology Associates
517 S. Coit Street
Florence, SC 29501
Phone Number: (843) 601-3246
The goal at Seasons Psychology Associates is to serve patients with understanding
and compassion while applying the latest empirically proven treatment strategies. We
believe that psychological science is underrepresented in psychotherapy and strive to
maintain the latest knowledge of proven interventions. We further believe that the
service should be individualized and tailored to the client’s and family's needs. In the
treatment of children, services involve collaboration with all involved entities including
but not limited to home, school, church, and extracurricular activities. With our flexible
hours and weekend time slots, we recognize the pressures on today's families and
individuals and work to provide psychological care that fits the busy lifestyle. With a
relaxing, comfortable, yet professional environment, we display an acceptance and
eagerness to serve your needs.
5. Horizon Psychological Services
215 Gilead Rd., Suite 200
Huntersville, NC 28078
Phone Number: (704) 960-2632
Horizon Psychological Services is a licensed practice that works with children,
adolescents, and adults. They strive to provide high quality, clinically sound assessments
that provide useful information for the client and other care providers. In addition, they
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work to create a positive and supportive environment when conducting therapy in order
to allow the client to deal more effectively with his or her difficulties.
6. Counseling and Psychological Services
Box 344022, Redfern Health Center
Clemson, SC 29634
Phone Number: (864) 656-2451
This practice is strongly committed to enhancing the mental health of our clients.
This practice is limited to Clemson University students. I am the director of Counseling
and Psychological Services (CAPS) at Redfern Health Center and our staff is composed
of fifteen full-time staff. We provide a safe environment for our students where they can
explore their issues and maximize the success of their learning experience. Regardless of
theoretical orientation utilized, the pervasive approach to treatment is multicultural in
application and differences, broadly defined, are valued and celebrated. CAPS is in the
Division of Student Affairs.
7. Jeannine Monnier, PhD
198 Rutledge Ave., Suite 6
Charleston, SC 29403
Phone Number: (843) 737-5012
In my practice, I specialize in working with those struggling with mood and anxiety
problems using a cognitive - behavioral therapies (CBT) approach. CBT uses techniques
that are based on scientific evidence to understand and treat psychological symptoms
such as: anxiety, worry, panic attacks, intrusive thoughts, obsessive thoughts,
compulsions, poor sleep, depressed mood, elevated mood, relationship problems, and low
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self-worth. Those I work with typically experience these symptoms in reaction to the
stress of everyday life, divorce or death of a loved one, traumatic stress (such as car
accidents and sexual assault), and/or a difficult childhood. I work with adults, children,
couples, and families to help reduce distress and to improve coping skills, communication
skills, assertiveness skills, sleep, hygiene and the like.
8. Catherine Anne Walsh, PhD, PA
1060 Cliffwood Dr., Suite B
Mt Pleasant, SC 29464
Phone Number: (843) 884-3121
My therapeutic goals are to provide a safe, caring place to focus on your life, your
future and the future of your loved ones. With over 20 years’ experience helping
couples, children, adolescents and adults successfully solve problems and achieve
happier, more effective and fulfilling lives, I can help you. For individuals, I use
cognitive-behavioral therapy for depression, adjustment, and all anxiety issues. I use
effective, evidence-based methods to help couples with John Gottman's couples'
approach. To help your child or adolescent I work with the school and your doctor to
provide the best integrated care plan. My recent work with individuals and couples
transitioning into retirement and later life stages involves individual and couples work to
help you make this the best time of your life. When you call, you will speak with me or I
will call you back - no need to talk with anyone else.
9. Merle J Tyroler, PhD, ABPP
222 West Coleman Blvd
Mount Pleasant, SC 29482
81
Phone Number: (843) 388-2212
Most of my clients are coming to me at a time in their lives when they feel "stuck" or
"out of solutions" or when they are experiencing a life change which feels overwhelming.
I listen carefully and with compassion about their experience of these issues. I help them
identify patterns that are no longer working and potential sources of strength. I read a lot
so I often will incorporate information from psychological research as well as from my
experience as a therapist (I have been in practice for 29 years). I help create new
possibilities for ways to view problems and for ways to resolve issues. I consider my
work to be very collaborative and want my clients to be engaged in the process. I am
eclectic in my approach and often will assign "homework". About 50% of my practice
involves working with couples who are experiencing marital, parenting, step-parenting,
or divorce-related stressors. I have earned the highest level of certification in clinical
psychology (ABPP).
10. Psychology Works
1601 Oak Street Suite 102
Myrtle Beach, SC 29577
Phone Number: (843) 449-0708
Dr. Montie Mills is a Clinical Psychologist licensed to offer a full range of
psychological services. She is the founder and director of Psychology Works, a private
practice organization dedicated to the promotion of family, community, and corporate
wellness. Her services include child/adolescent/adult evaluations and psychotherapy.
They are offered with an emphasis on brief, empowering interventions. Consultations are
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available to community groups and local businesses to increase productivity and job
satisfaction.
11. N. Kaye Finch, PhD
886 Johnnie Dodds Blvd Suite 202
Mount Pleasant, SC 29464
Phone Number: 843-881-6511
12. Brian K. Sullivan, PhD
Lifeworks LLC
250 Mathis Ferry Rd Suite 101
Mt. Pleasant, SC 29464
Phone Number: (843) 971-5171
13. Carey Washington, PhD
245 Business Park Blvd
Columbia, SC 29203
Phone Number: 803-699-1115
14. Eulalee Brand-Clingempeel, PhD
Family Psychology Institute
607 West Evans Street
Florence, SC 29501
Phone Number: (843) 662-6312
15. Frederic J. Medway, PhD
2016 Assembly Street
Columbia, SC 29201
83
Phone Number: (803) 920-2412
16. Jennifer A. Bennice, PhD
152 Cannon St., Suite A
Charleston, SC 29403
Phone Number: 843-330-8663
17. Lake Psychological Services
1 Windsor Cv., Suite 304
Columbia, SC 29223-1833
Phone Number: (803) 699-8887
18. Mark A. McClain, PhD
1 Poston Road, Suite 145
Charleston, SC 29407
Phone Number: 843-556-4157
19. Mary L Svendsen, PhD
2138 Ashley Phosphate Rd Suite 203
N Charleston, SC 29406
Phone Number: (843) 569-2904
20. Center for Emotional Restructuring
9 Maple Tree Ct., Suite B
Greenville, SC 29615
Phone Number: (864) 281-0600
21. Palmetto Health Psychology LLC
152 Cannon St., Suite A
84
Charleston, SC 29403
Phone Number: (843) 259-0794
22. Naval Hospital Beaufort
MCRD - Parris Island
Parris Island, SC 29902
Phone Number: (843)228-2913
23. Dutch Fork Psychological Services, LLC
1036 Kinley Road
Irmo, SC 29063
Phone Number: (803) 407-7099
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APPENDIX B
The following list provides therapists approved by the Anxiety Disorders Association of
America (ADAA), (www.adaa.org), for South Carolina.128 Interested parties may search
the website for programs in their area.
1. James C Ballenger, MD
Charleston, SC 29401
2. Jennifer A Bennice, PhD
Charleston, SC 29403
3. Sarah W Book, MD
Medical University of South Carolina
Charleston, SC 29425
4. Karen L Drummond, PhD
Columbia Psychological PA
Columbia, SC 29223
5. Roxann A. Hassett, LPC, MEd
Mt. Pleasant, SC 29464
6. Robin Joseph, MEd
Summerville Family Practice
Summerville, SC 29483
128
www.adaa.org (accessed on October 14, 2010).
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7. Ross M Muller, MA, LPC
Greenville, SC 29601
8. Ronald H. Reames, MA, LPC
Carolina Center for Counseling & Behavioral Interventions, LLC
Simpsonville, SC 29681-2319
9. Thomas W Uhde, MD
Medical University of South Carolina
Charleston, SC 29425
10. Jerome Yelder Sr., PhD, MBA
Comprehensive Health and Family Services
Columbia, SC 29230-0328
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