Treatments for performance anxiety in musicians across the lifespan: A systematic review and meta-analysis

Abstract

The availability of effective and timely interventions targeting the core features of debilitating performance anxiety (PA) is necessary to support musicians across the lifespan. The aim of this review was to provide an updated search of the research on treatments for PA in musicians and conduct a meta-analysis for available randomised controlled trials (RCTs). A systematic search identified 57 published articles on interventions targeting a reduction in PA symptoms in musicians. Results identified a range of intervention types, with cognitive-behavioural-based therapies most studied. Quality appraisal identified a low–moderate risk of bias, with a lack of detailed information on study design and participant awareness noted as contributors to studies falling in the moderate range. A total of 16 RCTs were included in the meta-analysis, which revealed treatment is more effective than control. Moderators of intervention delivery (individual or group) and age of participants (adolescents, college students, or a mixture of ages) were not significant. Future studies are recommended to be grounded in a theoretical model with the intervention targeting core contributing and maintaining factors, with a focus on greater methodological rigour. Comparing intervention types in future meta-analysis will aid in supporting one treatment above or equal to another.

Keywords

performance anxiety music performance anxiety social anxiety disorder systematic review meta-analysis treatments

Performance anxiety (PA) is a ubiquitous experience that often strikes when least desirable, such as in anticipation of, or during, a musical performance, a competition, or important presentation. The experience is typically unexpected and under-managed, highlighted by a strong fear of negative evaluation, reduced self-efficacy, and a strong sense to avoid, mask or flee the situation (Brugués, 2011). Formally situated in the Diagnostic and Statistical Manual of Mental Disorders 5th Edition TR (DSM-5-TR; American Psychiatric Association [APA], 2022) as a specifier for social anxiety disorder (SAD), PA captures a sub-category of socially anxious individuals whose fear of negative evaluation is isolated to instances of performing in public, whether in the context of public speaking, performing music, or competing in a sports competition. Differing terminology has been proposed to describe PA in musicians, with some preferring the term music performance anxiety (MPA, Kenny, 2023) over the diagnostic specifier from the DSM (Nicholl & Abbott, 2024). For the purpose of this review, we will utilise the term PA as an all-encompassing term as we explore interventions that aim to reduce the sequalae of PA symptomatology.

PA has been shown to particularly affect individuals in situations where performance is a fundamental component of their role, such as musicians, athletes, public speakers, and health professionals. Within these professions, individuals can often perform well in preparation for a performance but are impacted during the performance itself, such as when a musician recites a concerto beautifully in the practice room but freezes on stage. The introduction of an evaluative space (i.e., audience members or an outcome-based performance) often results in PA, where anxiety increases beyond a facilitative level. While some level of anxiety (or more appropriately arousal/activation) is understood to aid performance (Csikszentmihalyi, 1990), unmanaged PA can be detrimental not only to the performer and performance itself but also to the performance experience (Brugués, 2011). Importantly, the musician’s evaluation of potential threat is key to the level of anxiety they may experience. This is highlighted by both Osborne and McPherson (2019) and Murphy et al. (2024), where the appraisal of not only the performance environment, but also their internal experience has been demonstrated to impact the level of state anxiety experienced.

Regardless, the negative impact of PA has been demonstrated to contribute to negative perceptions and attitudes towards performance, such as an underestimation of ability (Abbott & Rapee, 2004), in addition to overall decreased coping perceptions, as well as one’s overall enjoyment in performing (Kenny, 2011). Current PA research is focused across a range of research areas (i.e., academic tests, music, and sport), with limited interdisciplinary synthesis, impacting how best to conceptualise and treat PA. Emerging research has demonstrated the applicability of sport psychology performance principals to musicians, with Osborne et al. (2014) demonstrating performance skills training is effective in building musicians’ mental skills and managing symptoms of MPA.

Research emphasising the distinguishing characteristics of different domains of PA is perhaps indicative of the desire to explore PA in an ecologically valid setting. Some researchers focusing on assessing and treating PA for musicians have suggested that musicians experience a particular type of PA that is potentially unique to their context (Brodsky, 1996; Kenny, 2005; Salmon, 1992). This is supported by the high prevalence rates of PA in musicians, as high as 60% in some studies (Fernholz et al., 2019), as well as the hypothesised unique technical nature of musical performance (Kenny, 2011). The anecdotally high dropout rate of musicians from the industry due to PA is not surprising given such high prevalence rates (Fernholz et al., 2019), and the accounts by individuals of the stress and pressure that performance can have on their overall health (Kenny, 2011). As such, the development of effective prevention and intervention strategies to assist this prevalent problem is warranted. Identifying efficacious and timely interventions is essential in addressing both the high prevalence of PA and dropout rates for musicians.

Previous systematic reviews

The most recent systematic review (Fernholz et al., 2019) assessed literature on the prevalence, risk-factors, and treatment effects for PA in musicians among professional musicians. Fernholz et al. (2019) built upon previous reviews (Brugués, 2011; Kenny, 2005) which noted the need to explore a wider range of studies to account for methodological problems. Tentative conclusions supporting cognitive-behavioural therapy (CBT) or cognitive-based techniques, and pharmacotherapy (i.e., beta-blockers) as the most effective interventions were made; however, meta-analytic techniques have yet to be employed comparing treatments or to assess aggregated effect sizes.

Kenny (2005) highlighted the impact of a lack of thorough definition, potentially effecting model development and treatment interventions based on model-based rigour. Kenny (2005) noted that the integration of PA as a subtype of SAD was potentially too restrictive, favouring conceptualising PA for musicians as a specific contextual form of anxiety, but also noted further exploration of the precipitating and maintaining factors associated with PA was needed to inform treatment. Current conceptualisations based on DSM-5-TR (APA, 2022) categorise PA for musicians as a contextual expression of SAD within a performance context, somewhat akin to public speaking anxiety. Kenny’s (2005) review highlighted the need to explore the role of cognition in PA for musicians further, which may further inform potential categories of MPA and the mechanisms required to be addressed in treatment.

Brugués (2011) concluded that cognitive-behavioural interventions appeared to result in the greatest reduction in symptom measure scores, while noting the need for preventative strategies to be disseminated. These included (1) choosing/performing a repertoire that the musician can perform well, (2) providing appropriate support for musicians and placing realistic expectations on musicians from a young age, (3) an emphasis on repeated exposure to performance situations in line with ability, and (4) early engagement with pedagogical processes around self-management anxiety strategies. These strategies, combined with awareness of PA symptoms, should result in the development of greater automaticity and cognitive confidence for musicians to perform in front of others (Brugués, 2011). Audition training, stress inoculation training, cue-controlled relaxation, and workshops all helped relieve a degree of stress for musicians. Brugués (2011) highlighted the lack of randomised studies as impeding a substantiative conclusion on the most efficacious treatment for PA in musicians. Of those categorised as being sound methodologically, a substantial number of papers appeared to explore ‘other’ interventions, indicating a lack of treatment protocols grounded in sound theoretical underpinnings (although this is improving with new research) and subsequent treatment targets. Treatments identified, however, were effective to a degree. Like Kenny (2005), this perhaps demonstrates the undiscovered ‘active ingredient’ in the treatment process for PA in musicians.

Interestingly, across three systematic reviews, authors identified three key challenges in concretely identifying effective treatments: (1) inconsistent assessment or diagnostic agreement, which is perhaps rooted in the lack of consensus on a definition for PA; (2) lack of methodological rigour, namely in randomisation, inclusion of control groups, and follow-up; and (3) assessment of subgroups of PA, that is, low versus high levels of PA, instrument subcategories, and stage of career. Importantly, previously published systematic reviews have provided a strong platform for further research to be conducted, and all emphasise the importance of methodological rigour in future research.

Previous meta-analysis

To the authors’ knowledge, only one meta-analysis has been published to examine the efficacy of treatments for PA in musicians. Recently, Faur et al. (2022) published a meta-analysis on cognitive-behavioural interventions for PA in musicians. This study explored an array of cognitive-behavioural interventions, including traditional CBT, interventions using specific cognitive or behavioural components, and Acceptance and Commitment Therapy (ACT) incorporating both randomised controlled and uncontrolled studies. The authors found CBT to have moderate to large effect sizes for most studies, with no statistically significant impact of treatment characteristics on outcomes. Results must be interpreted with caution as Faur et al. (2022) acknowledged that studies with no control groups rendered higher effect sizes than those with control groups. Interestingly, only two out of the 14 studies were individual treatments, and preliminary conclusions demonstrated no greater efficacy when compared with group interventions.

Aims and objectives

Over the last decade, there has been a strong increase in the number of studies exploring interventions for PA in musicians, such as ACT. Increased research focus on these new interventions has led to calls for their evaluation in the context of PA in musicians (Öst, 2014; Taylor et al., 2020). The consistent critique from previous reviews (Kenny, 2005) highlighted the need for methodological rigour and defined assessment protocols to assist in the development of consistent and replicable research. Therefore, the primary aim of this study is to provide an updated systematic review of available treatments for PA across the lifespan, with a focus on recognising the available assessment tools and quality assessment of the included studies, including a risk of bias analysis.

Recognising the breadth of studies available and the emphasis on quality and research integrity of past systematic reviews, the secondary aim of this article is to provide an updated meta-analysis of randomised controlled trials (RCTs) of interventions targeting PA in musicians. It is hypothesised that CBT will be the most efficacious treatment for PA in musicians in line with Fernholz et al. (2019), the findings of Faur et al. (2022), and guidelines for the treatment of SAD (Andrews et al., 2018). The authors also aim to assess the impact of the type of intervention (group vs. individual), and the population being treated (professional vs. college, vs. high school vs. mixed) on treatment outcomes.

Method

Protocol and registration

This article was structured in line with the Cochrane review guidelines (Higgins et al., 2022), following the PRISMA protocol (Hutton et al., 2015). This study was registered with the National Institute for Health Research (PROSPERO) on the 15 April 2022 [CRD42022316739], available from https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022316739.

Primary outcomes

We were interested in specifically assessing treatment effectiveness by exploring a reduction in PA symptomology as measured through symptom scores, self-reports, clinical interviews, or follow-up assessments. While acknowledging the number of other outcomes measured across studies, the focus of this review will be primarily on PA outcomes.

Search strategy

A systematic search of the databases PsycINFO, Scopus, MedLine, Cochrane, and IIPA was conducted. Keywords related to anxiety, PA, music, musicians, treatment, intervention, and management were used, resulting in a search line of (music* OR musician*) AND (‘performance anxiety’ OR ‘music performance anxiety’ OR ‘stage fright’) AND (intervention* OR treatment* OR therapy*). The search strategy is available on request. In addition to these searches, cited by works were also assessed. The final search was conducting on all databases on 20 April 2023.

Inclusion criteria

The inclusion criteria for this study were as follows:

a. Intervention was used to assess a change in PA scores;

b. Populations were musicians (any age);

c. Studies were published journal articles;

d. Studies were RCTs, experimental studies (uncontrolled trials), pilot studies, or case studies;

e. Studies were written or translated in English.

Data extraction

Data were extracted by the two authors using COVIDENCE (2022). After the search was completed and duplicates removed, each author individually assessed the title and abstract of the remaining papers. Of the studies included, Author 1 completed a full-text analysis in line with the inclusion criteria. Any disagreement was resolved by internal discussion; consultation of a third reviewer was not needed.

Appraisal of quality

Eligible articles were assessed to extract necessary data, including study design, participant characteristics, outcome variables, intervention type, treatment characteristics, and conclusions. Cohen’s d was calculated for data that was available and authors were contacted to collate missing data. Due to the abundance of studies and the variety of treatment types, only conclusions related to PA measures were included in this article. Results were analysed by treatment type (e.g., CBT) for comparison purposes.

Risk of bias was appraised using three methods. RCTs were evaluated using Cochrane’s Collaboration Tool for Assessing Risk of Bias (Higgins et al., 2011). Studies were assigned low, medium, or high, risk of bias for the following categories: selection bias, performance bias, detection bias, attrition bias, and reporting bias. Non-randomised studies were assessed using the Risk of Bias in Non-randomised Studies of Interventions (Sterne et al., 2016). Studies were assigned a low, some concern, or high risk of bias for the following categories: confounding, selection of participants, classification of intervention, deviations from intended interventions, missing data, measurement of outcomes, selection of the reported result. Case studies were assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports (2020). A second rater randomly assessed 10% of articles, and 80% agreement was obtained.

Data analysis

Comprehensive Meta-analysis Version 4 (CMA V4; Borenstein, 2022) was used to conduct the meta-analysis. The authors assumed that the true effect studies would vary given the range of methodologies and samples, and therefore ran the analysis using a random effects model (Borenstein, 2022). Hedge’s g was used to calculate the overall impact of symptom reduction among the studies, calculated using mean difference between groups divided by the pooled standard deviation. Heterogeneity was also calculated using Cochran’s Q to assess the variation in study outcomes across the studies. A large heterogeneity indicated there was significant variance between studies and the true intervention effects are not consistent across studies. Prediction intervals were reported in line with recommendations to indicate the estimation that the true effect size of comparable populations falls within a particular range (Borenstein, 2022). Funnel plots were used to examine risk of publication bias, where standard error was plotted for each study outcome to assess for asymmetry. The authors anticipated that given the scarce research on interventions for PA in musicians, neither small or large effects would be omitted from publication and that results would be reflective of current research available.

Subgroup analysis was conducted to assess the pooled effect size of treatment conditions against control conditions. The authors hypothesised that treatment groups would perform significantly better than control conditions. Moderation analysis was also conducted to assess for any effects of age of participants (adolescent, college, mixed), intervention type (intervention or control), and intervention setting (group or individual).

Results

Systematic review

Results of the search strategy

Following a comprehensive search, a total of 57 published articles were found to assess the impact of an intervention on PA scores in the context of musicians. Refer to Figure 1 for a comprehensive description of the search strategy.

Figure 1.

PRISMA Flow Chart of Study Selection Process (Page et al., 2021).

Demographics, assessment and outcomes measures

Please refer to Table 1 for details on the demographic, assessment measure, and outcomes measures in the studies.

Table 1.

Descriptive Statistics for Included Studies.

								Outcomes
No.	Study	N	%F	Age M	Design	Dx Interview	F/up	Performance anxiety	State/trait anxiety	Physical measures	Performance quality	Anxiety/ Depression	Other
1	Appel (1974)	29	?	31	RCT	?		PRCP		Pulse	✓
2	Bissonnette et al. (2015)	16	59	21	RCT	Self-report		PAI, PRCP	STAI		✓		ITQ
3	Bissonnette et al. (2016)	9	67	22	E	?			SUDS				ITQ
4	Braden et al. (2015)	62	100	14	RCT	Self-report	✓	MPAI-A			✓
5	Brantigan et al. (1982)	29	?	?	RCT	Self-report			STAI	EKG, Pulse, Blood Pressure, Saliva
6	Brodsky & Sloboda (1997)	54	50	36	RCT	Self-report	✓	AMPS, MPSS	STAI			POMS	DSP, MBI
7	Brooker (2018)	46	59	?	RCT	?			STAI		✓
8	Brooker (2019)	46	56	?	RCT	Self-report	✓		STAI
9	Cheng (2020)	61	?	?	E	Self-report				Heart/respiratory rate, skin temp.
10	Clark & Agras (1991)	34	?	?	E	SCID	✓	PRCP	STAI				SSQ, FSS, SADA, FNES
11	Clarke et al. (2020)	6	67	20	E	SCID-5-RV	✓	K-MPAI				DASS	MPFI, MHC
12	Cohen & Bodner (2019)	24	80	31	RCT	?		PAI	STAI		✓	BSI	DFS-2, PANAS,
13	Esplen & Hodnett (1999)	21	57	24	E	?			STAI				Performance Satisfaction
14	Gates et al. (1985)	34	?	26	RCT	Self-report			STAI	Pulse, Blood Pressure	✓
15	Gates & Montalbo (1987)	13	?	?	RCT	?			STAI	Pulse, Blood Pressure	✓
16	Harris (1987)	17	?	?	E	?	✓	PAI	STAI		✓
17	Hoffman & Hanrahan (2012)	33	88	42	RCT	?		PAI	STAI	Heart Rate	✓	BAI
18	James et al. (1977)	24	?	?	RCT	Self-report				Pulse, Blood Pressure	✓
19	James et al. (1978)	24	75	?	RCT	Self-report				Pulse, Blood Pressure	✓
20	James & Savage (1984)	31	?	?	RCT	Self-report				Pulse, Blood Pressure	✓
21	Juncos & Markman (2016)	1	100	?	Case Study	SCID-I		K-MPAI, PAI	SIAS				PHLMS, AAQ-2, BAFT, VLQ, OQ-45, ACQ
22	Juncos et al. (2017)	7	86	23	E	SCID-5	✓	K-MPAI					PHLMS, AAQ-2, BAFT, VLQ, ACQ, ESS
23	Kendrick et al. (1982)	53	91	19	RCT	?	✓		SAI	Pulse, Blood Pressure		SSS	EPESM, ASAS
24	Kennedy & Edmonds (2012)	1	100	12	E	Clinical Interview		K-MPAI-A	CSAI-2R			PS
25	Kenny et al. (2016)	1	0	55	Case Study	Clinical Interview
26	Kenny & Halls (2018)	68	66	45	E	Self-report	✓	K-MPAI	STAI		✓	PHQ	ASI
27	Khalsa & Cope (2006)	10	50	26	E	?		PAQ		PRMD		POMS	DFS-2
28	Khalsa et al. (2009)	45	56	25	E	?		PAQ		PRMD		POMS	PSS, PSQI
29	Khalsa et al. (2013)	135	57	24	E	?		PAQ, K-MPAI-A		PRMD		POMS	DFS-2
30	Kim (2005)	6	100	25	E	Clinical Interview		PARQ	STAI, LAS
31	Kim (2008)	30	100	20	E	Self-report		MPAQ	STAI	Temperature
32	Lazarus & Abramovitz (2004)	1	0	30	Case Study	Clinical Interview
33	Lin et al. (2008)	19	73	25	RCT	?		PAI	STAI		✓
34	MacAfee & Comeau (2020)	5	60	14	E	Self-report		K-MPAI-A	BAI		✓		SEMP
35	Mahony et al. (2022)	6	67	19	E	Self-report	✓	K-MPAI					AAQ-2, BAFT, PHLMS, SCS
36	Nagel et al. (1989)	20	60	?	RCT	Self-report		PAI, TAI	STAI				APQ, RBI
37	Norton et al. (1978)	1	100	20	Case Study	Clinical Interview
38	Nwokenna et al. (2022)	70	54	?	RCT	?	✓	K-MPAI					PSS
39	Osborne et al. (2007)	23	61	14	RCT	ADIS-IV	✓	K-MPAI	STAI	Blood Pressure, Pulse
40	Osborne et al. (2014)	31	71	19	E	?		PSI
41	Osorio et al. (2022)	54	0	?	RCT	Self-report	✓	K-MPAI	SSPS-P			SRQ-20
42	Reitman (2001)	18	72	27	RCT	Self-report		MPAQ	STAI, PARQ	EMG, Pulse
43	Rider (1987)	1	100	34	Case Study	Clinical Interview
44	Safirstein (1962)	1	100	34	Case Study	?
45	Shaw et al. (2020)	1	0	19	Case Study	Self-report	✓	K-MPAI					BAFT, AAQ-2, PHLMS
46	Sousa et al. (2012)	16	81	12	RCT	?				Blood Pressure, Pulse		DASS
47	Spahn et al. (2016)	21	67	22	E	Self-report	✓	K-MPAI	STAI		✓
48	Stanton (1993)	3	0	?	Case Study	?	✓	PAI
49	Stanton (1994)	40	?	?	RCT	Self-report	✓	PAI
50	Steyn et al. (2016)	36	58	?	E	?		CSAI-2					RPSW, BMSQ, FFMQ, STQ
51	Su et al. (2010)	59	56	?	E	?		K-MPAI-A
52	Sweeney & Horan (1982)	49	50	?	RCT	Self-report		PPAS	AATS, BAI	Pulse	✓
53	Tang & Ryan (2020)	35	?	21	E	?			SUDS		✓
54	Tarrant & Leathem (2007)	14	?	?	E	?	✓	M-PAS	STAI				EPQ-R
55	Valentine et al. (1995)	25	84	21	RCT	?		PAI, MPASS		Pulse	✓	NMA	EPI
56	Wells et al. (2012)	44	48	31	RCT	?			STAI				PANAS
57	Zhang (2022)	76	?	?	E	Self-report		MPSAS					SCL-90, SSS

Note. RCT: randomised controlled trial; E: Experimental; PRCP: Personal Report of Confidence as a Speaker; PAI: Performance Anxiety Inventory; STAI: State Trait Anxiety Inventory; ITQ: Immersive Tendencies Questionnaire; K-MPAI: Kenny Music Performance Anxiety Inventory; K-MPAI-A: Kenny Music Performance Anxiety Inventory for Adolescents; DSP: Derogatis Stress Profile; POMS: Profile of Mood States; MBI: Maslach Burnout Inventory; MPSS: Music Performance Stress Survey; AMPS: Appraisal of Music Performer’s Stress; PS: Positivity Scale; SAI: Self-actualisation Index; TAI: Test Anxiety Inventory; SSPS-P: Self-statement During Public Performance; SSQ: Self-statement Questionnaire; SRQ-20: Self-reporting Questionnaire; FSS: Fear Survey Schedule; SADA: Social Avoidance and Distress Scale; FNES: Fear of Negative Evaluation Scale; DASS: Depression Anxiety and Stress Scale; MPFI: Multidimensional Psychological Flexibility Inventory – Short Form; MHC: Mental Health Continuum – Short Form; DFS-2: Dispositional Flow Scale; BSI: Brief Symptom Inventory; PANAS: Positive and Negative Affect Scale; PSS: Performance Satisfaction Scale; PARQ: Performance Anxiety Response Questionnaire; MPAQ: Music Performance Anxiety Questionnaire; PHLMS: The Philadelphia Mindfulness Scale; AAQ-2: Acceptance and Action Questionnaire-2; BAFT: The Believability in Anxious Feelings and Thoughts scale; VLQ: Valued Living Questionnaire; OQ-45: The Outcome Questionnaire-45.2; ACQ: Anxiety Control Questionnaire; ESS: Experimental Shame Scale; SSS: Subjective Stress Scale; EPESM: Expectations of Personal Efficacy Scale for Musicians; ASAS: Anxiety Self-Assessment Scale; CSAI-2R: Competitive State Anxiety Inventory-2; PHQ: Patient Health Questionnaire; ASI: Anxiety Sensitivity Index; PRMDs: The Performance-Related Musculoskeletal Disorders Questionnaire; PAQ: Performance Anxiety Questionnaire; LAS: Likert Anxiety Scale; SEMP: Self-efficacy for Musical Performance; BAI: Behavioural Anxiety Inventory; APQ: Autonomic Perception Questionnaire; RBI: Rational Behaviour Inventory; MPASS: Music Performance Anxiety and Stress Scale; PPAS: Piano Performance Anxiety Scale; M-PAS: Musicians Performance Anxiety Scale; EPQ-R: Eysenck Personality Questionnaire Revised; FSS: Flow State Scale; NMA: Nowlis Mood Adjective; SCID: Structured Clinical Interview for DSM Disorders; ADIS: Anxiety and Related Disorders Interview Schedule; MPSAS: Music Performer’s Stage Anxiety Self-Rating Scale; SCL-90: Symptom Checklist 90; SSS: Subjective Satisfaction Scale; SUDS: Subjective Units of Distress; AATS: Adaption of Achievement Test Anxiety; PSI: Performance Skill’s Inventory.

Participant characteristics

There were a total of 1,639 participants across the 57 studies, with sample sizes ranging from 1 to 84. The mean age of participants 25.6 years, and the median was 24. The mean percentage of female participants across studies was 64.2%.

Study design characteristics

The study designs of included papers were: 25 RCTs (44%), 24 experimental (non-randomised) trials (E; 42%), and 8 case studies (14%). A total of 32% of studies included a follow-up outcome measure.

Assessment measures

Most studies relied on participant self-report or self-identification as experiencing PA (40%), while others used clinical interviews (11%), or structured diagnostic measures (9%). Of the structured diagnostic measures, the Structured Clinical Interview for DSM disorders (SCID; First et al., 2016) and Anxiety Disorders Interview Schedule (ADIS; Silverman & Albano, 1996) were used. A large group of studies did not report an assessment measure to identify participants’ level of PA (40%).

Outcome measures

Across studies, there was some inconsistency in the use of a specific measure to assess PA. Many studies used a specific PA scale (63%), with the Kenny Music Performance Anxiety Inventory (K-MAPI and MPAI-A; Kenny, 2009, 2011) and Performance Anxiety Inventory (PAI; Nagel et al., 1989) used most frequently. Only six studies (11%) use a clinical interview, most of which were case studies. A State/Trait anxiety measure was also commonly used (54%), such as the State Trait Anxiety Scale (38%, STAI; Spielberger, 1983), often in conjunction with another PA measure. Several studies included a physiological measure to assess PA, such as pulse or blood pressure (33%). Performance quality was also measured to assess the impact of anxiety on performance (35%), in addition to including a stress/depression index (21%). A proportion of studies used other outcomes measures to help answer their specific research questions (41%). A small proportion of studies relied on clinician judgement and subsequently did not report using any psychometric outcome measures (7%).

Treatment programme characteristics

A wide variety of treatments were utilised to target PA, focusing on either trait (characteristic) or state (situational) anxiety. The studies that targeted state PA did so in manufactured performance environments to elicit an analogue experience to performing in front of a naturalistic audience.

Of the 57 papers included in this review, the majority utilised a form of CBT to assess a reduction in PA symptoms. Yoga, hypnotherapy, pharmacotherapy, and music therapy were the next most common treatments. A large portion of studies assessed novel treatments, such as specific skills courses to target PA. A summary of the treatment characteristics is found in Table 2.

Table 2.

Summary of Interventions for Performance Anxiety in Musicians.

Study	Population	Instrument	Treatment protocol	Intervention used pre-post-performance	Effect size at pre-post, post-FU (Cohen’s d)	Conclusion
Cognitive-behavioural-based interventions
Clark & Agras (1991)	Mixed	?	CBT: Participants completed 5 weeks of intervention either CBT and/or pharmacotherapy. CBT focused on coping strategies, identifying cognitive distortions, and exposure. Buspirone (5 mg) or placebo was taken 3–12× per day.Group 1: CBT + PlaceboGroup 2: CBT + buspironeGroup 3: Buspirone ONLYGroup 4: Placebo ONLY		0, 2.31 0.65, 0.50 0.80, 0.18 1.37, 0.43	Improvements in all groups following intervention. No significant difference between groups at the end of treatment. Significant difference between CBT v. non-CBT (placebo or buspirone) at FU (p < .05).
Braden et al. (2015)	High School Students	Mixed	CBT: Participants completed 8-week group intervention or wait-list control.Group 1: ‘Unleash Your Music Potential’ programme.Group 2: Wait-list control.	✓	NR NR	Significant reduction in self-reported PA for the intervention group, maintained at follow-up (p < .001). No significant impact on judge-rated MPA or performance quality.
Brodsky & Sloboda (1997)	?	?	CBT: Participants completed cognitive-behavioural psychotherapy in three different settings.Group 1: ‘Somatron’ massaging chair + music.Group 2: Pre-recorded music onlyGroup 3: Counselling only.		NR NR NR	Significant reduction in self-reported PA following intervention (p = .004) but not maintained at FU (NS). Reduction in PA total between post-follow-up (p < .005). No interaction effect of the subgroups (NS).
Kendrick et al. (1982) *	Mixed	Piano	CBT: Participants completed 3 × 1.5- 2 hr group intervention sessions over 3 consecutive weeks or wait-list control.Group 1: Attention Training + Behavioural RehearsalGroup 2: Behavioural Rehearsal onlyGroup 3: Wait-list control.		1.17, 0.42 0.62, 0.24 0.80, 0.14	Significant reduction in both the treatment groups compared to the control on the PASS (p < .01), but no significant difference between the two treatment conditions (NS), or reduction in the STAI (NS).
Lazarus & Abramovitz (2004)	Professional Musician	Violin	CBT: Individualised psychotherapy over 20 sessions.		NR	The participant claimed to be ‘cured’, noting distancing themself from his music as a key component to reduction in anxiety.
Rider (1987)	Professional Musician	Cellist	CBT: Individualised psychotherapy over 8 sessions.		NR	Self-reported increase in satisfaction when playing, improvement in overall playing, and self-confidence.
Tarrant & Leathem (2007)	College Music Students	Mix	CBT: Participants completed 6 sessions of 1-hr group psychotherapy.		0.32	Significant reduction in anxiety scores when comparing pre- and follow-up (p = .03).
Nagel et al. (1989) *	College Music Students	Mix	CBT: Intervention (6 weeks of biweekly 1-hr group) or wait-list control.Group 1: Progressive Muscle Relaxation, Cognitive Therapy, and Biofeedback training.Group 2: Wait-list control.		2.17 0.37	Significant reduction in anxiety when comparing the treatment to the control group (p < .001). Also, a significant reduction in trait anxiety for the treatment when compared to the control group (p = .02).
Harris (1987)	College Music Students	Mix	CBT: Intervention (6 weeks of biweekly 2-hr group) or wait-list control.Group 1: CBT.Group 2: Wait-list control.		1.45 0.08	Significant reduction following intervention in anxiety between pre- and follow-up on the PAI (p < .001) but not STAI (NS).
Kenny & Halls (2018)	Community Musicians	Mix	CBT: Intervention provided in a 1-day workshop format (5 hr), followed by 3 weeks of suggested activities.Group 1: Chilled (Rapee et al., 2006) adapted for musiciansGroup 2: Anxiety Sensitivity protocol (Gardenswartz & Craske, 2001).[All participants completed a ‘placebo’ control condition prior to the workshop in the format of a power-point presentation].		NR NR	Improvement in scores for state anxiety and performance quality for both groups. Results were maintained for the CBT group and improved for the AS group at follow-up.
Osborne et al. (2007) *	High School Musicians	Mix	CBT: Intervention included combined 3 × 1 hr group and 4 × 45-min individual sessions).Group 1: Active TreatmentGroup 2: Control group.		NR NR	Overall reduction in anxiety following the treatment (p = .42), but this was not significant compared to participants who did not adhere to the programme and the control group (NS).
Norton et al. (1978)	?	Piano	CBT: Individualised psychotherapy over 15 sessions.		NR	The participant reported a reduction in anxiety, highlighting the relaxation and cognitive rehearsal as most effective.
Sweeney & Horan (1982) *	College Music Students	Piano	CBT: Specific individual skill intervention (6 × 1 hr week), combined, or control or wait-list control.Group 1: Cue-controlled relaxation.Group 2: Cognitive Restructuring.Group 3: CCR + CR.Group 4: Control group (musical analysis course).Group 5: Wait-list control.	✓	1.24 0.98 1.17 0.61 0.23	Significant reduction in PA across all groups. Combined treatment was not proved to be more effective at reducing anxiety (NS).
Clarke et al. (2020)	College music students	Vocalist	ACT: Participants completed group-based ACT for Anxiety Disorders (Eifert & Forsyth, 2005) over 6 × 2 hr. No control condition.		NA	Significant reduction in K-MPAI scores at pre-post and pre-follow-up, although scores remained in the clinical range.
Juncos & Markman (2016)	College music student	Violin	ACT: Participants completed individualised ACT for Anxiety Disorders (Eifert & Forsyth, 2005) over 10 × 1 hr. No control condition.		NA	Significant reduction in PAI scores at pre-follow-up (p < .05), and K-MPAI below the clinical range for MPA.
Juncos et al. (2017)	College music students	Vocalist	ACT: Participants completed individualised ACT for Anxiety Disorders (Eifert & Forsyth, 2005) over 12 × 1 hr. No control group.		> 0.80	Significant reduction in K-MPAI scores post-treatment (p < .05), with 4/7 students below the clinical range post-treatment.
Mahony et al. (2022)	College music students	Vocalist	ACT: Participants were individually coached over 6 × 1 h online sessions. The course followed Hill and Oliver’s (2019) book Acceptance and Commitment Coaching: Distinctive Features.		1.90	Significant reduction in K-MPAI scores post-treatment (p < .05), with mean scores falling above the cut-off for clinical MPA.
Shaw et al. (2020)	College music student	Vocalist	ACT: A singing teacher was trained to use ACT (7 h approx.). The teacher provided 6 × 1 hr sessions with a student over 4 months. No control condition.		NA	No PA results were comparable as the K-MPAI was not given at the commencement of the intervention.
Appel (1974) *	College Music Students	Piano	Systematic Desensitisation: Participants completed treatment (8 × 1 hr) or control.Group 1: Participants trained in systematic desensitisation.Group 2: Participants trained in musical analysis and performance rehearsal techniques.Group 3: Control.	✓	1.02 0.26 0.02	There was a significant reduction in all PA measures in the SD group (p < .05), but only performance errors were reduced in the analysis group. No significant difference in control group after repeating the performance.
Reitman (2001) *	Mixed	Mixed	Systematic Desensitisation: Participants completed intervention (8 × 75-min group sessions including homework exercises) or wait-list control.Group 1: Verbal coping systematic desensitisation.Group 2: Music-assisted systematic desensitisation.Group 3: Wait-list control.		1.21 2.49 0.72	Significant reduction in PA across all groups. No significant differences among groups between pre- and post-intervention.
Bissonnette et al. (2015) *	College Music Students	Pianists + ?	Virtual Reality: Intervention (6 × 1 hr) or control.Group 1: VR training sessions exposed to classical performance scenarios.Group 2: Control.	✓	Refer to paper.	Significant reduction in PA across treatment group. Post-hoc analysis revealed significant effect of treatment only on females with higher pre-test anxiety.
Bissonnette et al. (2016)	College Music Students	Pianists + Guitarists	Virtual Reality: Participants completed VR training sessions exposing participants to performance environments. Intervention was completed over 3 weeks (6 × 1 hr). No control group.	✓	1.13	Significant decrease in SUDs pre- and post-treatment and a significant increase in performance quality.
Pharmacotherapy
Brantigan et al. (1982)	College Music Students	?	Double-blind crossover design using propranolol or placebo. Participants completed a recital in front of a live audience and were given one condition on Day 1, and the alternate on Day 2. Some students (7) participated in a third day and were given terbutaline.	✓	NR	Decrease in physical and reported symptoms of ‘stage fright’ in the propranolol group when compared to the terbutaline, and placebo groups (p < .05).
Gates et al. (1985)	College Music Students	Vocalists	Double-blind crossover design using 20, 40 or 80 mg of Nadolol or a placebo. Participants performed in front of a live audience, and 48 hr later with a placebo.	✓	NS	Subjective reports of performance anxiety did not significantly differ across groups (NS).
Gates & Montalbo (1987)	College Music Students	Vocalists	Double-blind crossover design using Nadolol or a placebo. Participants were given either before performance, which was repeated with the alternate condition 48 hr later.	✓	NS	The authors concluded no significant difference between the two conditions on performance anxiety (NS).
James et al. (1977) *	Mixed	String	Double-blind crossover design using Oxprenolol (40 mg). Participants were given either before performance, which was repeated with the alternate condition 48 hr later.	✓	NS	No significant reduction in performance anxiety (NS).
James et al. (1978)	Mixed	String	Double-blind crossover design using Oxprenolol (?mg). Participants were given either before performance, which was repeated with the alternate condition 48 hr later.	✓	NR	Statistically significant reduction in performance anxiety measured by subjective scales (NR).
James & Savage (1984)	High School Students	Mixed	Double-blind crossover design using Nadolol (40 mg) or Diazepam (2 mg). Participants were given either before performance, which was repeated with the alternate condition 48 hr later.	✓	NR	No significant result on self-rated performance anxiety, although a positive impact on physiological technique (i.e., bowing) (NS).
Osorio et al. (2022) *	Professional Musicians	Vocalists	Double-blind crossover design using Oxytocin (24UI) or placebo over two performance days.	✓	NS	No change in reported anxiety.
Hypnotherapy
Stanton (1993)	Mixed	Mixed	Participants completed 2 × 50 min intervention sessions using success imagery and Rational Emotive Therapy (RET). No control condition.		NR	Reduction in performance anxiety at post-treatment maintained at follow-up (NR).
Stanton (1994) *	College music students	?	Participants completed intervention (2 × 50 min intervention sessions in 1 week) or control.Group 1: Relaxation, positive suggestion, and symbolic success.Group 2: Control condition spent the time talking about their courses and discussing ways they reduce stress levels during performances.		1.26, 1.98 0.37, 0.36	Reduction in performance anxiety for the treatment group (p < .01) maintained at 6-month follow-up.
Brooker (2018)	College music students	Piano	Participants completed intervention (2 × 1-hr sessions over a 2-week period).Group 1: Cognitive Hypnotherapy (CH)Group 2: EMDRGroup 3: Control		NR NR NR	Significant post-treatment effects were found at follow-up for both treatment conditions.
Brooker (2019) *	College music students	Piano	Participants completed intervention (2 × 1-hr sessions over a 2-week period) or control.Group 1: Cognitive Hypnotherapy (CH)Group 2: EMDRGroup 3: Control		1.92 1.31 0.29	Significant post-treatment effects were found at follow-up for both treatment conditions
Yoga
Khalsa & Cope (2006)	High school students	Mixed	Participants completed intervention (8 weeks) or control.Group 1: Participants were able to join up to 14 classes and optional weekly evening discussion session related to performance anxiety/progression.Group 2: Control.		NR NR	Statistically significant reductions in performance anxiety were found in three areas of performance anxiety (practice, group, and solo performances) on the PAQ (NR). When comparing the condition, only the solo condition was significant (p = .05) in reduction of anxiety.
Khalsa et al. (2009)	High school students	Mixed	Participants completed in intervention (8 weeks) or control.Group 1: Participants completed 3 × 1-hr yoga or meditation classes a week, 6 × 2.5 hr group yoga and discussion sessions, and 1× private yoga instruction.Group 2: Yoga only (no lifestyle discussions).Group 3: Control.		NR NR NR	Statistically significant reductions in performance anxiety for both intervention groups (p < .05) on the PAQ, however, no significant between-group effects (NS). Impacts were maintained at follow-up for group 2 (p < .05) but not group 1 (NS).
Khalsa et al. (2013)	High school students	Mixed	Participants completed in intervention (8 weeks) or control.Group 1: Participants completed 3 × 1 hr yoga or meditation classes.Group 2: Control.		0.39 0.02	Statistically significant reductions in performance anxiety in group (p < .05) and solo performances (p < .01) performance anxiety using the PAQ. Participants in the treatment group also demonstrated somatic/cognitive anxiety (p < .001) and lower end-of-treatment performance anxiety (p < .001) on the MPAI-A.
Sousa et al. (2012)	Primary school students	Flute	Participant completed intervention (7 weeks) or control.Group 1: Qigong instructed yoga daily for 30 minGroup 2: Wait-list control.		0.53 0.19	Performance anxiety was not explicitly measured, and no significant reduction in anxiety (NS).
Lin et al. (2008) *	College Music Students	Mixed	Participants completed treatment (8 weeks of 1 × 1.5 hr) or control.Group 1: Meditation instruction and practiceGroup 2: Wait-list control.	✓	NR	Results indicated a reduction in performance anxiety in the experimental group, however significance levels were not reported.
Music Therapy
Cheng (2020)	College Music Students	Mixed	[Treatment protocol not reported]Group 1: Imaginary music relaxation groupGroup 2: Somatosensory vibration music group.		NR	No results were reported on the impact on performance anxiety.
Kim (2005)	College Music Students	Mixed	Treatment (psychoeducation, breathing exercises, free improvisation, conversation/discussion, and homework exercises) occurred 6 × 30 min. No control.		0.28	Significant reduction in Likert-reported and STAI-state scores from pre-post (p < .028), while no significant difference on scores on the PARQ or STAI-T.
Kim (2008)	College Music Students	Piano	Participants completed treatment (6 × 30 min) or control.Group 1: Improvised music-assisted desensitisationGroup 2: Music-assisted progressive muscle relaxation and imagery.		0.38 0.87	The Improvised group saw a reduction in STAI-A scores but not MPA scores at post-test. The PMR group saw statistically significant reduction in MPA scores and STAI-A scores. No significant differences between the two groups.
Other Treatments
Kennedy & Edmonds (2012)	Primary School Student	Piano	Biofeedback: Single-session biofeedback training was paired with diaphragmatic breathing. No control condition.		NR	Significant reduction in performance anxiety scores post-intervention.
Wells et al. (2012)	Professional Musicians	Mixed	Biofeedback: Participants were asked to examine a piece of music for 5 min prior to performing it. Following, participants completed their intervention (30-min) or control and then repeated the performance.Group 1: Slow breathing + biofeedbackGroup 2: Slow breathing onlyGroup 3: Control	✓	NR	Significant reduction in state anxiety scores when comparing the intervention and control groups. Slow breathing was sufficient, and biofeedback deemed not necessary.
Kenny et al. (2016)	Professional musician	String	Psychotherapy: 10× 1 hr weekly sessions of Intensive Short-term Dynamic Psychotherapy (ISTDP).		NR	Clinician reported the participant experienced a positive reduction in performance anxiety symptoms.
Safirstein (1962)	Professional musician	Piano	Psychotherapy: Four years of psychotherapy (unknown number of sessions).		NR	Reported ability to perform in the absence of anxiety following treatment.
Su et al. (2010)	Primary School Students	Voice	Relaxation: Participants completed a brief 10 min relaxation breathing exercise biweekly before choir. No control.		NR	Unclear as to the extent of reduction in MPA following the breathing exercises.
Esplen & Hodnett (1999)	?	?	Guided Imagery: Participants used a 10-min guided imagery script that explored performance control and support. Participants used the recording for the 7 days leading up to a performance.		1.02	Significant reduction in anxiety (p < .001).
Valentine et al. (1995) *	College Music Students	Mixed	Alexander Technique: Treatment or control.Group 1: Treatment (15 sessions).Group 2: Control.		0.62 0.19	Reduction in performance anxiety for intervention group, although not statistically significant when compared to control.
MacAfee & Comeau (2020)	Primary School Students	Piano	Self-review: Following a pre-intervention performance, participants were emailed a positive self-review video, asked to watch it 4-times per week and practice the piece while modelling the video.		0.17	No significant reduction in PA scores following the intervention. Self-modelling appeared to be useful for some participants.
Spahn et al. (2016)	College Music Students	Mixed	Audition Training: Treatment (14 weekly 90 min workshops) or control.Group 1: Audition training (working on performance practice, exercises for coping with PA, psychoeducation).Group 2: Control.		0.79 0.02	Significant reduction in anxiety for the intervention group when compared to the control group for state anxiety, and performance quality (self- and judge-rated).
Nwokenna et al. (2022) *	College Music Students	Mixed	Performance course: Treatment (16 × 40-min sessions across 8 weeks) or control.Group 1: Group performance course (dance and relaxation, music analysis/discussion).Group 2: Control.		NA NA	Significant improvement in performance related stress post-intervention (p = .001). No significant change at follow-up.
Cohen & Bodner (2019) *	College Music Students	Mixed	Performance skills course: Treatment (11 week 90 min) or wait-list control.Group 1: Performance skills group (mental skills training, developing physiological awareness, enhancing musical communication, and simulated musical performances).Group 2: Wait-list control.		1.02 0.39	Significant reduction in performance anxiety and state anxiety scores between the treatment and control groups. A significant reduction in scores was seen individually in the treatment and control groups.
Hoffman & Hanrahan (2012) *	Mixed	Mixed	Skills Group: Treatment (3 × 1 hour group) or control.Group 1: Group mental skills (self-awareness, thinking patterns, and self-talk).Group 2: Wait-list control.		0.41 0.16	Significant reduction in self-reported performance anxiety (p < .05) on the PAI. This was maintained at FU.
Osborne et al. (2014)	College Music Students	Mixed	Skills Group: Participants completed 2 × 90 min lectures, followed by a week of 60-min group master classes (breathing training, goal setting, cognitive reappraisal).		0.99	Significant reduction in pre- post-anxiety.
Steyn et al. (2016)	College Music Students	?	Skills Group: Participants completed intervention (7 weeks) or control.Group 1: Group mental skills (attention, arousal, psychological centering, and breathing techniques).Group 2: Control group.		0.66 0.20	Significant reduction in somatic (p = .012) and cognitive (p = .003) anxiety when compared to the control group.
Tang & Ryan (2020)	?	?	Expressive Writing: Participants completed intervention or control 10 min prior to a performance.Group 1: Writing task on their upcoming performance.Group 2: Control group wrote about an event that happened recently.	✓	NS	No significant reduction in self-reported performance anxiety. Post-hoc analysis reported a reduction in self-reported anxiety ONLY for those who reported higher self-talk (p < .04).
Zhang (2022)	?	?	Relaxation: Participants completed an analysis of their performance experience and looked to identify ways to develop relaxational cues when performing.		NR	Indicated rate of reduction on stage related anxiety. Results not statistically reported.

Note. NR: Not Reported.

Papers included in the meta-analysis.

Treatment results summary

Cognitive-behavioural therapies

A variety of treatments fall under the umbrella of CBT (i.e., traditional CBT, individual cognitive or behavioural components, ACT). Thirteen studies reported use of a traditional CBT intervention, five studies used ACT, two studies used systematic desensitisation (i.e., exposure) and two used virtual reality (VR). Treatments varied in application (individual vs. group psychotherapy vs. clinician training music teachers). In traditional CBT interventions, cognitive (i.e., cognitive restructuring, thought challenging) and behavioural (i.e., behavioural activation, exposure) strategies were effective, while acknowledging the beneficial impact of non-specific therapeutic factors (i.e., therapist modelling, the therapeutic relationship, active engagement). Within the ACT interventions, a reduction of ‘experiential avoidance’ was noted as a factor contributing to some reductions in PA.

Pharmacotherapy

Seven studies employed pharmacotherapy to reduce PA experienced by participants. Each study adopted a double-blind randomised crossover design in relation to a repeated live performance. Results were not able to demonstrate a clear reduction in PA across studies; however, some studies found that trait anxiety and performance quality improved following the intervention. Participants appeared to consistently self-report stable PA.

Hypnotherapy

Three studies used hypnotherapy as the mechanism to reduce the level of PA experienced by participants. Results showed an increase in enjoyment during performances; however, when compared with Eye Movement Desensitisation and Reprocessing (EMDR), EMDR was demonstrated to be more effective at reducing both trait anxiety and self-reported PA.

Yoga

Four studies assessed a yoga intervention for PA. Results demonstrated that PA scores significantly reduced following the intervention, particularly during ‘solo’ performances.

Music therapy

Three studies used a unique technique to reduce PA in musicians. Studies varied significantly in their treatment approach, with a focus on reducing distress. Results showed active engagement in a music-based therapy programme encouraged performance development and reduced overall stress. Statistical significance, however, was not obtained.

Other

Fourteen studies used a unique mechanism to target PA symptoms. These included psychodynamic therapy, biofeedback, music analysis, audition training, performance skills courses, and the Alexander Technique. Results varied significantly with difficulty assessing true change in PA scores. Many participants appeared to self-report reductions in PA; however, many studies did not include any psychometric measures.

Overall treatment effects

Overall treatment effects were assessed by measuring the effect size of the impact of the intervention on each group. Means and standard deviations were used to calculate the Cohen’s d effect sizes, where scores above 0.2 were deemed low, scores above 0.5 deemed moderate, and scores above 0.8 were deemed large effect sizes (Cohen, 2013). As detailed in Table 2, treatment effect sizes using Cohen’s d ranged from 0 to 2.49, from no effect to large effect sizes for the 36 papers with data available (63%). Cohen’s d for follow-up studies ranged from 0.37 to 2.31; however, only three papers (5%) had available follow-up data. For papers that used CBT, intervention was demonstrated to be more effective when compared with control groups, with findings maintained at follow-up for several studies. Combined cognitive and behavioural strategies were deemed more effective than individual components alone. Effect sizes for pharmacological, psychodynamic, and all but one ACT intervention was unable to be calculated due to missing data. Cognitive hypnotherapy and EMDR interventions demonstrated medium to large effect sizes (maintained at follow-up); while yoga and music therapy interventions that reported data demonstrated moderate effect sizes when compared with control groups (nil to small effect size). Studies which used systematic desensitisation demonstrated large effect sizes, while skills groups demonstrated low to medium effect sizes. VR interventions noted large effect sizes, but insignificant results when compared with controls, perhaps demonstrating active participation in an intervention can impact true assessment results.

Risk of bias

Randomised controlled studies (RCTs) were assessed using Cochrane’s Collaboration Tool for Assessing Risk of Bias (Sterne et al., 2019). Non-randomised controlled studies were assessed using the Risk of Bias in Non-randomised Studies of Interventions (Sterne et al., 2016). Risk of bias for Case Studies was assessed using the JBI Critical Appraisal Checklist for Case Reports (Moola et al., 2020). Results can be found in Tables 3 to 5. The overall risk of bias for the studies included in the review is low–moderate, with a lack of detailed information on study design and participant awareness noted as key contributors to studies falling in the moderate risk of bias range. For RCTs, ‘deviation from intervention’ was deemed ‘unclear’ for several studies, notably where the authors were unable to determine if participants were at all aware of the condition they were placed in or whether the authors took into consideration their facilitation of interventions as impacting their overall interpretation of results. For non-randomised studies, similar queries around the possibility of confounding participants’ understanding of the treatment and possible impacts on treatment effects, in addition to general reporting of results. For case studies, many did not report adequate outcome measures or results to demonstrate meaningful change or impact of the intervention. These findings are in line with the results of Fernholz et al. (2019) where methodological shortcomings were identified, including similar difficulties with participant selection, diagnostic tools, and issues with allocation.

Table 3.

Risk of Bias for Randomised Controlled Trials.

		Type of bias					Outcome
No.	Study	Randomisation	Deviation from intervention	Outcome data	Outcome measurement	Reporting	Overall risk of bias
1	Appel (1974)	+	/	+	+	+	/
2	Bissonnette et al. (2015)	+	+	+	+	+	+
3	Braden et al. (2015)	/	+	+	+	+	/
4	Brantigan et al. (1982)	+	+	+	+	+	+
5	Brodsky & Sloboda (1997)	+	+	+	+	+	+
6	Brooker (2018)	+	+	+	+	+	+
7	Brooker (2019)	+	+	+	+	+	+
8	Cohen & Bodner (2019)	/	+	+	+	+	/
9	Gates et al. (1985)	+	+	+	+	+	+
10	Gates & Montalbo (1987)	+	+	+	+	+	+
11	Hoffman & Hanrahan (2012)	/	/	+	+	+	/
12	James et al. (1977)	+	+	+	+	+	+
13	James et al. (1978)	+	+	+	+	+	+
14	James & Savage (1984)	+	+	+	+	+	+
15	Kendrick et al. (1982)	+	+	+	+	+	+
16	Lin et al. (2008)	+	+	+	+	+	+
17	Nagel et al. (1989)	/	+	+	+	+	/
18	Nwokenna et al (2022)	+	+	+	+	+	+
19	Osborne et al. (2007)	+	+	+	+	+	+
20	Osorio et al (2022)	+	+	+	+	+	+
21	Reitman (2001)	+	+	+	+	+	+
22	Stanton (1994)	+	+	+	+	+	+
23	Sweeney & Horan (1982)	+	+	+	+	+	+
24	Valentine et al. (1995)	+	+	+	+	+	+
25	Wells et al. (2012)	+	+	+	+	+	+

Note. + ‘low risk of bias’; / ‘some concerns’; − ‘high risk of bias’; NA, ‘not applicable’.

Table 4.

Risk of Bias for Non-Randomised Trials.

		Type of bias							Overall risk of bias
No.	Study	Pre-/during-Intervention			Post-intervention
		Confounding	Selection	Classification	Deviation	Missing data	Measurement	Reporting
1	Bissonnette et al. (2016)	+	+	+	+	+	+	+	+
2	Cheng (2020)	/	+	+	+	+	+	+	/
3	Clark & Agras (1991)	+	+	+	+	+	+	+	+
4	Clarke et al. (2020)	+	+	+	+	+	+	+	+
5	Esplen & Hodnett (1999)	+	+	+	+	+	+	+	+
6	Harris (1987)	+	+	+	+	+	+	+	+
7	Juncos et al. (2017)	+	+	+	+	+	+	+	+
8	Kennedy & Edmonds (2012)	+	+	+	+	+	+	+	+
9	Kenny & Halls (2018)	+	+	+	+	+	+	+	+
10	Khalsa & Cope (2006)	/	+	+	/	+	/	+	/
11	Khalsa et al. (2009)	+	+	+	/	+	/	+	/
12	Khalsa et al. (2013)	+	+	+	/	+	/	+	/
13	Kim (2005)	+	+	+	+	+	+	+	+
14	Kim (2008)	+	+	+	+	+	+	+	+
15	MacAfee & Comeau (2020)	+	+	+	+	+	+	+	+
16	Mahony et al. (2022)	+	+	+	/	+	+	/	+
17	Osborne et al. (2014)	+	+	+	+	+	+	+	+
18	Sousa et al. (2012)	/	+	+	+	+	+	+	/
19	Spahn et al. (2016)	+	+	+	+	+	+	+	+
20	Stanton (1993)	/	/	+	+	/	+	/	/
21	Steyn et al. (2016)	+	+	+	+	+	+	+	+
22	Su et al. (2010)	+	+	+	+	+	+	+	+
23	Tang & Ryan (2020)	+	+	+	+	+	+	+	+
24	Tarrant & Leathem (2007)	+	+	+	+	+	+	+	+
25	Zhang (2022)	/	/	/	/	/	/	/	/

Note. + ‘low risk of bias’; / ‘some concerns’; − ‘high risk of bias’; NA ‘not applicable’.

Table 5.

Risk of Bias for Case Reports.

		Item
No.	Study	1. Were patient’s demographic characteristics clearly described?	2. Was the patient’s history clearly described and presented as a timeline?	3. Was the current clinical condition of the patient on presentation clearly described?	4. Were diagnostic tests or assessment methods and the results clearly described?	5. Was the intervention(s) or treatment procedure(s) clearly described?	6. Was the post-intervention clinical condition clearly described?	7. Were adverse events (harms) or unanticipated events identified and described?	8. Does the case report provide takeaway lessons?
1	Juncos & Markman (2016)	+	+	+	+	+	+	?	+
2	Kenny et al. (2016)	+	+	+	?	+	?	-	+
3	Lazarus & Abramovitz (2004)	+	+	+	?	+	+	-	+
4	Norton et al. (1978)	+	+	+	?	+	+	-	+
5	Rider (1987)	+	+	+	?	+	-	-	+
6	Safirstein (1962)	+	+	+	?	?	?	-	?
7	Shaw et al. (2020)	+	+	+	/	+	+	?	+

Note. + ‘low risk of bias’; − ‘high risk of bias’; ? ‘Unclear risk of bias’; NA, ‘not applicable’.

Meta-analysis

Results of the search strategy

A total of 25 published RCTs were found to assess the impact of an intervention on reducing PA scores in participants. Of these, data for only 16 studies were available following contact with authors.

Participant characteristics

There were a total of 543 participants included across the 16 studies. Samples sizes ranged from 16 to 70, with the mean age of participants 25.7 years. The mean percentage of female participants was 63.7%.

Assessment and outcome measures

All except one study relied on participant self-report of PA. One study used the ADIS (Silverman & Albano, 1996), while the remaining studies did not report a diagnostic measure. While having a specific outcome measure was an eligibility criterion for this study, multiple PA measures were used. The STAI (Spielberger, 1983) was used commonly as a secondary anxiety measure.

Overall treatment effects

Hedge’s g within-group effect sizes were calculated for the 16 studies (N = 543) assessing PA symptoms at pre- and post-intervention (see Figure 2). For treatment conditions (n = 22), the pooled effect size was g = 1.21, confidence interval (CI) = [0.89, 1.53], p < .001, indicating an overall large effect size (Cohen, 1988) of interventions on reducing PA scores. The prediction interval ranged from −0.21 to 2.82, indicating the true effect size in 95% of all comparable populations falls in this interval (Borenstein, 2022).

Figure 2.

Forest Plot of Hedges’ g for Performance Anxiety Symptoms Pre- and Post-Intervention.

For control groups (n = 17), the pooled effect size was g = 0.57, CI = [0.28, 0.86], p < .001, indicating an overall medium effect size (Cohen, 1988) for control conditions in reducing PA scores. The prediction interval ranged from −0.62 to 1.83, indicating the true effect size in 95% of all comparable populations falls in this interval (Borenstein, 2022).

The between-groups analysis indicated a significant difference between the intervention and control groups, p = .004, indicating treatment groups resulted in an overall significantly greater reduction in symptoms scores. Tests of heterogeneity indicated the presence of high significant heterogeneity, Q(1) = 7.790, p = .005. This suggests a significant level of dispersion among the treatment characteristics, indicating that it is difficult to isolate the ‘active ingredient(s)’ resulting in any meaningful change.

Given the support for CBT the suggested efficacious intervention for PA (Brugués, 2011; Fernholz et al., 2019), we wanted to compare the effect sizes of CBT against other interventions. However, given the significant variability of interventions that fall under the cognitive-behavioural umbrella, any analysis would have been met with significant variability/discrepancy. As such only an intervention versus control analysis was completed.

Moderators

The categorical variables of type of intervention delivery (individual or group) and age of participants (adolescents, college students, or a mixture of ages) were explored in a meta-regression analysis for PA symptoms using the random effects model. Two separate meta-regressions found that there was no significant impact detected for intervention delivery, Q = .200, p = .654, or age of participants, Q = 5.02, p = .171, on the strength of intervention effects.

Publication bias

Funnel plot (Figure 3) examination indicated a skew towards smaller studies being included with a larger effect size. One study demonstrated significant publication bias. Trim and fill analysis under the random effects model remains unchanged.

Figure 3.

Funnel Plot of Standard Error by Hedges’ g for RCTs of Interventions Targeting Performance Anxiety.

Discussion

The large number of studies included in this systematic review and meta-analysis is evidence of the volume and breadth of research that is actively investigating efficacious treatments for PA in musicians. Building on the work of Fernholz et al. (2019), this systematic review presents an updated review of published articles exploring treatments to reduce PA in musicians across the lifespan. The broad inclusion criteria utilised culminated in the inclusion of 57 papers, with randomised controlled and non-randomised experimental designs, as well as case studies that explored a wide range of treatment modalities comprising individual and group formats, personalised and standardised interventions, and both short- and long-term treatment. The current review additionally aimed to include a standardised assessment of research quality and treatment effectiveness. To the authors’ knowledge, this is the first study to systematically review interventions for PA in musicians across the lifespan in addition to assessing study quality and including a meta-analysis.

The systematic review found a substantial number of intervention approaches were used to target PA symptoms in musicians across the lifespan. CBT was noted as the most studied treatment approach, with some interventions specifically targeting a core component of CBT (i.e., cognitive restructuring, systematic desensitisation, or exposure). This finding is in line with recommended interventions for SAD (Andrews et al., 2018), where CBT is identified as the first line of treatment. A vast number of studies explored novel treatments, with skills and performance classes emerging as a popular way to target PA among college and younger musicians. Many of the ‘other’ interventions assessed focused on modifying the way in which interventions were delivered (i.e., skills courses and seminars). Interestingly, participant preference resulted in differences in approach success, with some participants preferring more cognitive approaches (Kendrick et al., 1982), while others benefitted more from behavioural interventions (Lazarus & Abramovitz, 2004). Therapeutic factors were also identified to contribute to the outcome of studies, including therapist modelling (Norton et al., 1978) and the importance of the therapeutic relationship (Sweeney & Horan, 1982). Unsurprisingly, participant engagement was also noted as a key component to participant results (Osborne et al., 2007). The timing of interventions was also explored, with Su et al. (2010) finding that certain components of interventions given prior to 30 min before a performance were not effective. These findings are valuable for the development of further interventions, which can continue to assess specific cognitive components to target in treatment, therapeutic factors involved in the change process, and the timing of interventions to best support outcomes.

The quality and impact of interventions targeting PA in musicians varied. A wide range of studies were deemed effective, spanning from children to college musicians to professionals; while others were unable to demonstrate superiority to control groups, or the significance of findings could not be maintained at post or follow-up. Many findings needed to be interpreted with caution, as often participants with higher pre-intervention scores had the greatest reduction in PA symptomology, even though many still met the clinical cut-off for severe PA, necessitating greater emphasis on achieving clinically significant outcomes.

The quality of papers included in this review also supports recommendations for the continued development of rigorous research methods and practice. Under-reporting of components (i.e., participants being aware of treatment characteristics, or the impact of researchers running interventions) was often the key difficulty in assessing any impact of bias. It is recommended that future studies ensure the reporting of all methodological components, particularly when including characteristics about the running of interventions (participant awareness of the intervention/controls available, length of treatment in keeping with reporting guidelines). Uncontrolled trials and case studies continue to have merit in the emerging assessment of processes involved in treatment effectiveness; however, more rigorous RCTs are required. When assessing for confounding factors, it is suggested that studies also examine intervention-related factors such as engagement, therapeutic relationship, and the individual processes being targeted. Overall, these findings are in line with Fernholz et al. (2019), indicating an improvement in the quality of studies being developed.

The meta-analysis demonstrated that for RCTs, interventions for PA were found to be more effective than controls. The moderators of intervention types (group or individual) and participant age (adolescent, college, or mixed) did not demonstrate more significant contributions to outcomes. The original hypothesis, that cognitive-behavioural interventions would be the most effective, was not able to be tested. Given the limited number of ‘similar’ studies that included traditional elements of CBT, any comparison would be misleading. The significant variability and heterogeneity among the data indicates the need to analyse studies based on shared components, which was not possible here. The findings of Faur et al. (2022) indicate that CBT is effective in treating PA in musicians, with future studies examining the specific cognitive and behavioural components that contribute to the effectiveness of cognitive-behavioural-based therapies being warranted.

Kenny (2005) and Brugués (2011) highlighted the lack of methodological rigour as a matter of urgency more than a decade ago. The findings of this article highlight the development of more sound research approaches to PA in musicians; however, further development is still warranted. This is perhaps a symptom of the larger challenge around the definition, assessment, and disorder-specific model used in the field of PA. The spurious number of assessment tools, lack of conceptual focus, and lack of replicability continue to present substantial challenges. The wider acceptance and incorporation of models for SAD (Barlow, 2002; Clark & Wells, 1995; Heimberg et al., 2014; Hofmann, 2007; Rapee & Heimberg, 1997) is supported by the launch of the performance specifier from the DSM-IV/5 working group (Heimberg et al., 2014), where SAD researchers acknowledged the role of the ‘audience’ (perceived or real) in inducing anxiety in performers, but did not take away from the acknowledged complexity of the technical aspects of the individual’s craft (i.e., performing music). This understanding provides a base for researchers to explore unique components of the performance situation that contribute to an increase in anxiety that is not otherwise experienced. The essence of PA is the ability for performers to perform unhindered by substantial anxiety in the rehearsal or practice space, but the introduction of an audience causes a marked increase in anxiety. Some researchers in MPA have acknowledged the similarities between the cognitive models of SAD and PA (Osborne & Franklin, 2002); however, a consensus has not been reached on the applicability and continued use of the well-established cognitive models.

One key component that has not been assessed in this review is the basis of the interventions conducted. That is, what theoretical lens is being applied to justify the intervention chosen for the population. On face value, many studies used a transdiagnostic approach, perhaps linking to the use of Barlow’s (2002) triple vulnerability model, highlighted by Kenny (2011), where the reduction in overall anxious apprehension is the basis for intervention. Complementary model components could allow for the further study of the complexities that are suggested in MPA research (i.e., depression/hopelessness, early life experiences, maladaptive schemas, generational, and parental influences). The complexities can be acknowledged, on one hand, but they do not account for the absence of an updated model or reliance on a simplified anxiety induction model. Future reviews should look to assess the theoretical basis of interventions, exploring the relevant mechanisms being targeted which can support more rigorous intervention development, that is, the relevant cognitive processes targeted in SAD treatments, and examine their applicability to PA in musicians, such as has been explored by Osborne and Franklin (2002).

Interestingly, the movement away from interventions simply targeting symptom reduction and working towards ‘optimal performance’ and flourishing was a positive inclusion in recent papers (e.g., Cohen & Bodner, 2019). It was also encouraging to see the emerging recognition that PA in musicians and sport are more interrelated than separate (Braden et al., 2015; Osborne et al., 2014). This could lead to the development of performance skills courses (pre-emptive, rather than post-mortem interventions) such as that of Steyn et al. (2016), Hoffman and Hanrahan (2012), and Cohen et al. (2019). The emergence of therapies such as ACT (in addition to the increased focus on somatic and active therapies, such as yoga) also indicates the growth in less targeted interventions that positively impact other areas of well-being. This supports the development of incorporating lifestyle and general well-being components into interventions.

A stepped-care approach for mild and moderate anxiety could benefit individuals with mild or a recent experience of PA; such approaches are starting to manifest in the literature (Osborne et al., 2014). Individuals who specifically identify challenges in one area of performance (e.g., fear of judgement) could be directed to a specific skills-based course prior to being referred to more intensive 1:1 formalised cognitive-behavioural treatments, whereas those who identify a fear of making a mistake (e.g., playing a wrong note) could be supported through technical and practice-based training. Further developments would need to be made regarding methodological consistency for such studies, noting appropriate measurement of PA and intervention fidelity (i.e., from trained professionals such as psychologists). Within a stepped-care approach, consensus could be developed on the targeting of specific processes.

Limitations

The conclusions of this study are impacted by the breadth of studies included in this article. The large number of studies included demonstrates difficulty within the literature in synthesising the necessary core features of interventions to achieve symptom reduction. The specific focus on English and published papers also reduces the breadth that is possible for this review, recognising the significant number of unpublished dissertations that were excluded. With those in mind, and while the quality of the papers may have been impacted, the scope of the interventions provided and number of participants available would have been greater. The significant number of papers included in the meta-analysis also limits the specificity of the results generated. As there was significant heterogeneity, the efficacy of CBT when compared with other interventions was not possible to assess. Future research should also examine the theoretical underpinnings of the interventions available, in addition to the findings based on the assessment measures used. Many interventions rely on unique self-report measures; it would be useful to recognise the relative strength of findings based on standardised assessment tools and symptom outcome measures.

Conclusion

The aim of this systematic review and meta-analysis was to assess the efficacy of available interventions targeting a reduction in PA symptoms in musicians across the lifespan. The results of the systematic review identified a vast array of available treatments, with a focus on targeting general cognitive and behavioural components of PA. The meta-analysis found that in RCTs, interventions for PA in musicians are more effective than for controls, demonstrating a large average effect size relative to wait-list controls. Moderators of intervention type (individual vs. group) and age of participants demonstrated no significant effect on treatment efficacy.

Based on the findings of this study, there is evidence for the recommendation of CBT as the first line of treatment for PA in musicians. This recommendation is based predominantly on the effect sizes of interventions (medium to large). Recognising the variation in treatment application and results, emphasis should also be placed on assessing other factors associated with intervention success, including maintaining processes and identifying other ‘active ingredients’ in treatment to reduce PA for musicians across the lifespan.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Thomas J Nicholl

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