Pharmacotherapy for performance anxiety disorders: Occasionally useful but typically contraindicated

Design and Evaluation of a Collective Preventive Program for Musical Performance Anxiety (ConfiDance)

Musical performance anxiety (MPA) is considered a subtype of social phobia and affects musicians who must face musical exposure in public, potentially severely affecting their emotional stability and significantly impairing the quality of their performance. This research has utilized previous scientific knowledge on the issue and a qualitative approach to musicians' needs through focus groups in order to design a collective preventive program for MPA that could be implemented within the training curriculum of professional musicians. To evaluate the adequacy of the preventive program 'ConfiDance', a pilot test was conducted with a sample of 17 professional musicians in training, all post-graduate students in classical music performance. For the pilot test, a quasi-experimental model with a repeated measures methodology (pre-post and one-year follow-up after application) was carried out. The results indicate a significant decrease in MPA after the program implementation, with a notable improvement in effect one year post-application, demonstrating an even greater positive impact over time. These data should be interpreted cautiously due to sample limitations but represent an opportunity for the future implementation of a program that can prevent and treat MPA in music education centers.

Examining a Group Acceptance and Commitment Therapy Intervention for Music Performance Anxiety in Student Vocalists

Music performance anxiety (MPA) is a distressing and persistent anxious apprehension related to musical performance. The experience of MPA forces many musicians to give up performing or develop maladaptive coping mechanisms (e.g., avoidance or substance use), which can impact their career and wellbeing. High levels of MPA in students and vocalists are reported in the literature. Vocalists present a unique challenge for clinicians in that vocal and breathing mechanisms, required for performance, are negatively impacted when anxious. Acceptance and commitment therapy (ACT) has demonstrated efficacy for the treatment of a range of psychological problems including social anxiety disorder (of which MPA may be indicated as a subtype). This study sought to investigate whether group-based ACT may be a feasible and effective intervention for MPA in Australian student vocalists and aimed to design an intervention that could be adopted by music education providers. Potential participants (N = 31) completed an online survey including demographic questions and outcome measures. Six vocal students (four females; two males; aged M = 20.33 years) with elevated MPA scores participated in the ACT for MPA group program and 3-month follow-up. Group sessions were 2 h each week for six consecutive weeks. Participants were followed up 3 months post-intervention via online survey. There was a significant increase in psychological flexibility and significant decreases in MPA and psychological inflexibility. Gains were maintained at 3-month follow-up. The current study offers preliminary evidence for the feasibility and effectiveness of a group-based ACT protocol for musicians with performance anxiety which may be incorporated into tertiary performance training curricula.

Psychotropic Medication Prescribing in Iraq/Afghanistan Veterans and Vietnam Era Veterans With Posttraumatic Stress Disorder

A new generation of veterans from Iraq/Afghanistan wars is seeking psychotropic pharmacotherapy for posttraumatic stress disorder (PTSD) from the Veterans Health Administration, but little is known about differences in prescribing practices between this group and Vietnam era veterans with the same diagnosis. The Veterans Health Administration administrative data for fiscal year 2012 were used to compare prescribing for 155,631 Iraq/Afghanistan veterans and for 327,634 Vietnam era veterans diagnosed with PTSD. The proportion of veterans who were prescribed psychotropic medications (altogether and within five of seven medication classes) were not substantially different between veteran groups. Iraq/Afghanistan veterans were more frequently prescribed prazosin (p < 0.0001, relative risk = 1.51). However, the number of prescriptions for anxiolytics/sedatives/hypnotics as well as prazosin and opiates filled by this younger group was lower by a small magnitude (Cohen's d < 0.2). Iraq/Afghanistan veterans have good access to psychopharmacological treatment for PTSD but fill somewhat fewer prescriptions than Vietnam era veterans.

Combined Neuropeptide S and D-Cycloserine Augmentation Prevents the Return of Fear in Extinction-Impaired Rodents: Advantage of Dual versus Single Drug Approaches

BACKGROUND

Despite its success in treating specific anxiety disorders, the effect of exposure therapy is limited by problems with tolerability, treatment resistance, and fear relapse after initial response. The identification of novel drug targets facilitating fear extinction in clinically relevant animal models may guide improved treatment strategies for these disorders in terms of efficacy, acceleration of fear extinction, and return of fear.

METHODS

The extinction-facilitating potential of neuropeptide S, D-cycloserine, and a benzodiazepine was investigated in extinction-impaired high anxiety HAB rats and 129S1/SvImJ mice using a classical cued fear conditioning paradigm followed by extinction training and several extinction test sessions to study fear relapse.

RESULTS

Administration of D-cycloserine improved fear extinction in extinction-limited, but not in extinction-deficient, rodents compared with controls. Preextinction neuropeptide S caused attenuated fear responses in extinction-deficient 129S1/SvImJ mice at extinction training onset and further reduced freezing during this session. While the positive effects of either D-cycloserine or neuropeptide S were not persistent in 129S1/SvImJ mice after 10 days, the combination of preextinction neuropeptide S with postextinction D-cycloserine rendered the extinction memory persistent and context independent up to 5 weeks after extinction training. This dual pharmacological adjunct to extinction learning also protected against fear reinstatement in 129S1/SvImJ mice.

CONCLUSIONS

By using the potentially nonsedative anxiolytic neuropeptide S and the cognitive enhancer D-cycloserine to facilitate deficient fear extinction, we provide here the first evidence of a purported efficacy of a dual over a single drug approach. This approach may render exposure sessions less aversive and more efficacious for patients, leading to enhanced protection from fear relapse in the long term.

The reappraisal of benzodiazepines in the treatment of anxiety and related disorders

Benzodiazepines (BDZs) continue to be shrouded in controversy, mainly because of dependence associated with their long-term use and some of their side effects. Despite treatment recommendations favoring newer antidepressants, BDZs are still commonly prescribed for anxiety and related disorders. Recent studies have demonstrated that long-term use of BDZs for these conditions can be effective and safe and that BDZs can be combined with psychological therapy and antidepressants to produce optimal outcomes. Such findings, along with a failure to convincingly demonstrate the overall superiority of alternative pharmacotherapy for anxiety and related disorders, have given an impetus to a reconsideration of the role of BDZs. This article reviews BDZs and other pharmacotherapy options for anxiety and related disorders and suggests that treatment guidelines should acknowledge that BDZs can be used as first-line, long-term pharmacological treatment for panic disorder, generalized anxiety disorder and social anxiety disorder.

Systemic or intra-amygdala infusion of the benzodiazepine, midazolam, impairs learning, but facilitates re-learning to inhibit fear responses in extinction

A series of experiments used rats to study the effect of a systemic or intra-amygdala infusion of the benzodiazepine, midazolam, on learning and re-learning to inhibit context conditioned fear (freezing) responses. Rats were subjected to two context-conditioning episodes followed by extinction under drug or vehicle, or to two cycles of context conditioning and extinction with the second extinction under drug or vehicle. A 20-min extinction under vehicle resulted in better long-term inhibition on a subsequent drug-free retention test than a 4-min extinction under vehicle, or a 20-min, as well as a 4-min, extinction under drug. However, a 20-min, as well as a 4-min, second extinction under drug was just as effective in producing long-term inhibition as a 20-min second extinction under vehicle and this inhibition was greater than that produced by a 4-min second extinction under vehicle. Initial extinction of 5, 10, or 20 min were equally effective in producing long-term inhibition when the second extinction under drug was 20 min; and 5-, 10-, or 20-min second extinction under drug were equally effective in producing long-term inhibition when the initial extinction was 5 min. A 4- or 20-min second extinction under an infusion of drug into the basolateral amygdala (BLA) was as effective in producing long-term inhibition as a 20-min second extinction under vehicle and was more effective than a 4-min second extinction under vehicle. The results show that midazolam impairs learning to inhibit fear responses but spares and even facilitates re-learning this inhibition.

Behavioral correlates of anxiety

The tripartite model of anxiety includes three response domains: cognitive (most often identified by self report), behavioral, and physiological. Each is suggested to bring a separate element of response characteristics and, in some cases, potentially independent underlying mechanisms to the construct of anxiety. In this chapter, commonly used behavioral correlates of anxiety in human research, including startle reflex, attentional bias, and avoidance tasks, as well as future tasks using virtual reality technology will be discussed. The focus will be in evaluating their translational utility supported by (1) convergent validity with other measures of anxiety traits or anxiety disorders, (2) their use in identifying neural and genetic mechanisms of anxiety, and (3) ability to predict treatment efficacy.

Yoga ameliorates performance anxiety and mood disturbance in young professional musicians

Yoga and meditation can alleviate stress, anxiety, mood disturbance, and musculoskeletal problems, and can enhance cognitive and physical performance. Professional musicians experience high levels of stress, performance anxiety, and debilitating performance-related musculoskeletal disorders (PRMDs). The goal of this controlled study was to evaluate the benefits of yoga and meditation for musicians. Young adult professional musicians who volunteered to participate in a 2-month program of yoga and meditation were randomized to a yoga lifestyle intervention group (n = 15) or to a group practicing yoga and meditation only (n = 15). Additional musicians were recruited to a no-practice control group (n = 15). Both yoga groups attended three Kripalu Yoga or meditation classes each week. The yoga lifestyle group also experienced weekly group practice and discussion sessions as part of their more immersive treatment. All participants completed baseline and end-program self-report questionnaires that evaluated music performance anxiety, mood, PRMDs, perceived stress, and sleep quality; many participants later completed a 1-year followup assessment using the same questionnaires. Both yoga groups showed a trend towards less music performance anxiety and significantly less general anxiety/tension, depression, and anger at end-program relative to controls, but showed no changes in PRMDs, stress, or sleep. Similar results in the two yoga groups, despite psychosocial differences in their interventions, suggest that the yoga and meditation techniques themselves may have mediated the improvements. Our results suggest that yoga and meditation techniques can reduce performance anxiety and mood disturbance in young professional musicians.

A meta-analysis of D-cycloserine and the facilitation of fear extinction and exposure therapy

BACKGROUND

Translational research suggests that D-cycloserine (DCS), a partial N-methyl-D-aspartate (NMDA) receptor agonist, might facilitate fear extinction and exposure therapy by either enhancing NMDA receptor function during extinction or by reducing NMDA receptor function during fear memory consolidation. This article provides a quantitative review of DCS-augmented fear extinction and exposure therapy literature.

METHODS

English-language journal articles that examined DCS augmented with fear extinction or exposure therapy were identified through public databases from June 1998 through September 2007, through references of originally identified articles and contact with DCS investigators. Data were extracted for study author, title, and year; trial design; type of subject (animal vs. human; clinical vs. nonclinical); sample size, DCS dose, and timing in relation to extinction/exposure procedures; dependent variable; group means and SDs at post-extinction/exposure; and follow-up outcome.

RESULTS

D-cycloserine enhances fear extinction/exposure therapy in both animals and anxiety-disordered humans. Gains generally were maintained at follow-up, although some lessening of efficacy was noted. D-cycloserine was more effective when administered a limited number of times and when given immediately before or after extinction training/exposure therapy.

CONCLUSIONS

This meta-analysis suggests that DCS is a useful target for translational research on augmenting exposure-based treatment via compounds that impact neuroplasticity. D-cycloserine 's major contribution to exposure-based therapy might be to increase its speed or efficiency, because the effects of DCS seem to decrease over repeated sessions. This information might guide translational researchers in discovering more selective and/or effective agents that effectively enhance (or reduce) NMDA receptor function.

NMDA Partial agonist reverses blocking of extinction of aversive memory by GABA(A) agonist in the amygdala

The ability to extinguish aversive memories is of significant clinical interest. The amygdala plays an important role in emotional conditioning and its experimental extinction. It has been suggested that gamma-aminobutyric acid (GABA) agonists retard extinction and that consolidation of extinction involves N-methyl-D-aspartate receptor (NMDAR)-mediated plasticity. The aim was to further explore the interaction between GABA and NMDA in the amygdala in consolidation of experimental extinction in the rat. To that end conditioned taste aversion (CTA) was used. In CTA, the amygdala has been reported to subserve both acquisition and extinction. The GABA(A) receptor agonist, muscimol, administered into the amygdala immediately after the first extinction session, caused lasting disruption of extinction of CTA for at least 2 weeks. However, the administration of GABA(A) receptor antagonists had no effect on extinction kinetics. Microinfusing the partial NMDA agonist D-cycloserine together with or after muscimol infusion reversed the blocking effects of muscimol. These findings could bear relevance to the potential involvement of extinction abnormalities in behavioral disorders, and their amelioration.

PERFORMANCE ANXIETY, DYSFUNCTIONAL ATTITUDES AND GENDER IN UNIVERSITY MUSIC STUDENTS

The aims of this study were twofold: 1) to investigate the relationships between anxiety and general dysfunctional attitudes, perfectionism, and the need for approval in the solo performance examination of Turkish university music students, and 2) to examine the effects of perfectionism, need for approval, and gender on anxiety. Fifty-four instrumental music students participated in this study. Research data were collected using the Beck Anxiety Inventory (Beck, Epstein, Brown, & Steer, 1988) and the Dysfunctional Attitudes Scale (Weissman & Beck, 1978). The results revealed that there are significant positive correlations between anxiety and total score of dysfunctional attitudes, and the need for approval (p < .05). The ANOVA results also showed that while there was no main effect of perfectionism, need for approval and gender had significant effects (p < .05) on anxiety. However, interaction effects of perfectionism, need for approval, and gender on anxiety were not significant. Results are discussed in the context of related literature.

Anwendung - Effektivität - Aufrechterhaltung

Zusammenfassung. Hintergrund: Die “Effektivität“ psychotherapeutischer Interventionen, für die “Wirksamkeit“ in kontrollierten Studien belegt wurde, hängt in der Versorgungspraxis von zahlreichen Faktoren ab, die bisher meist isoliert diskutiert wurden. Fragestellung: Es soll geklärt werden, ob Fragen zur Wirkung psychotherapeutischer Interventionen heuristisch fruchtbar in formalen Modellen integriert werden können. Methoden: Zur Modellbildung wird dabei die Boolesche Logik verwendet. Die Möglichkeiten dieses Ansatzes werden anhand von Beispielen zur Therapie psychischer Störungen aufgezeigt. Ergebnisse: Die beispielhaften Modelle hilfreicher Interventionen setzen voraus, dass 1. die Intervention aktiviert wird, wenn eine therapeutische Veränderung notwendig ist (Anwendung), dass 2. die Intervention die intendierte Veränderung herbeiführen kann (Effektivität) und dass 3. die erreichte Veränderung nachhaltig ist (Aufrechterhaltung). Schlussfolgerungen: Die vorgestellten “Booleschen Interventionsmodelle“ postulieren spezifische zeitliche Muster (“Attraktoren“) und erlauben eine neuartige vergleichende Analyse von Interventionsformen und Versorgungssystemen.

Influence of ethanol withdrawal on fear memory: Effect of D-cycloserine

Animals made dependent via an ethanol (ETOH) -containing liquid diet (6% v/v) for 14 days were subjected to a contextual fear conditioning paradigm 3 days after the last consumption day. After conditioning, rats were subjected to four extinction trials by exposing the animals to the conditioned context and their freezing was evaluated for each trial. Immediately after the first extinction trial, animals were injected with D-cycloserine (DCS) 5 mg/kg i.p., a dose that did not influence the extinction in control rats. Spontaneous recovery of learned fear was tested seven days after the last extinction trial. The following day, animals were subjected to a reacquisition or a reinstatement procedure and their freezing responses evaluated 24 h later. The present study shows that: 1. discontinuation from chronic ETOH administration facilitated the formation of a new fear memory concomitant with a marked resistance to being extinguished, 2. administration of DCS (5 mg/kg) facilitated the extinction process only in ETOH withdrawn rats, 3. both reinstatement and reacquisition procedures restored the increased freezing in ETOH withdrawn animals after extinction, 4. DCS administered immediately after the first extinction trial prevented the increase in freezing following both reacquisition and reinstatement. The enhanced sensitivity to the facilitatory effect of DCS in ETOH withdrawn animals may be mediated by adaptive changes in N-methyl-D-aspartate (NMDA) receptor provoked by ETOH dependence.