Table 3.

Intrapersonal factors associated with MPA.

Demographics	Gender	There is broad consensus that women of all ages experience MPA more widely and acutely than men (consistent with generalized anxiety) and that gender is a significant factor in predicting MPA (Papageorgi et al., 2007; Thomas and Nettelbeck, 2014; Burin and Osório, 2017; Fernholz et al., 2019).
	Sociocultural factors	James (2000) reported significant differences in the quantity of stress experienced from occupation-related stressors across different nationalities. No explanation was given to account for sociocultural differences. Based on his study investigating levels of self-esteem among American, Australian and Chinese music students, Brand (2004) concluded that self-perception and self-esteem differ across cultural groups. His findings indicate the importance of cultural differences in understanding the development, as well as the prevention and treatment, of MPA. Unfortunately, as no further studies have been conducted in this area (Brugués, 2019), understanding of this important topic remains minimal. This represents an important gap in understanding, as all person relationships to MPA are arguably culturally conditioned. Mumm et al. (2020) suggest that transcultural differences should be taken into account when diagnosing and treating MPA in musicians from different cultural backgrounds, such as individualistic versus collectivistic societies.
Biography factors	Family & Teachers	Influence of parental expectations (pressure), severity of pedagogical style and pressure from teachers (Brugués, 2019; Burin et al., 2019). See Kenny and Holmes (2015, 2018) and Wiedemann et al. (2020) for detailed discussion regarding the complex relationship between parenting and attachment style and MPA.
	Conditioning	Aversive experiences from past performances causing conscious or unconscious anxiety-triggers (Kenny, 2006; Osborne and Kenny, 2008; Burin et al., 2019). Negative experiences arguably increase the chance of perceiving performance situations as threatening, increasing the likelihood of MPA symptoms manifesting.
Personality traits	Coping style	Inadequate, or maladaptive, coping strategies significantly predict MPA (Sinden, 1999; van Fenema et al., 2013; Thomas and Nettelbeck, 2014); Difficulty coping with performance-related arousal and negative cognitions perceived as contributors to MPA (Burin et al., 2019).
	Self-efficacy	Several studies have shown a positive correlation between low self-efficacy and MPA (Sinden, 1999; Liston et al., 2003; Papageorgi et al., 2010) and a negative correlation between high self-efficacy and MPA (Craske and Craig, 1984). The significant association between self-efficacy and anxiety has been attributed to the interaction between low confidence in one’s ability to execute a task and physiological, psychological and behavioral anxiety symptoms (Bandura, 1991).
	Perfectionism	Previously thought to be a unidimensional construct, perfectionism is now defined as a multidimensional personality trait characterized by setting exceedingly high personal standards in search of flawless performance and tendencies toward overly critical self-evaluations (Hewitt and Flett, 1991). Perfectionism comprises both adaptive and maladaptive components – adaptive elements (perfectionistic strivings) are associated with positive behaviors, intrinsic motivation and achievements whereas maladaptive elements (perfectionistic concerns) are associated with negative behaviors and outcomes including excessive worry about making mistakes, self-doubt and negative responses to perceived failures or imperfections (Hewitt and Flett, 1991; Frost et al., 1993; Mor et al., 1995; Sinden, 1999; Stoeber and Otto, 2006; Stoeber and Eismann, 2007). Dimensions of maladaptive perfectionism are associated with depression, anxiety, excessive self-criticism, low self-esteem, disordered eating, maladaptive cognitions, performance dissatisfaction, fear of negative evaluation and burnout (Hewitt and Flett, 1991; McGrath, 2012; Zhukov, 2019). Studies of musicians reveal negative dimensions of perfectionism to strongly predict MPA as well as extrinsic motivation and psychological distress (Stoeber and Otto, 2006; Stoeber and Eismann, 2007; Kobori et al., 2011; Diaz, 2018). Pressure from self, associated with excessively high standards, is one of the most frequently cited causes of MPA (Kenny et al., 2014; Burin et al., 2019). The relationship between perfectionism and MPA is highly complex because both phenomena are multi-faceted and encompass both positive and negative dimensions, and because the relationship can be mediated by third variables, such as self-efficacy (Mor et al., 1995).
	Low self-esteem	Low self-esteem is associated with the prediction of MPA (Sinden, 1999; Papageorgi et al., 2007; Chan, 2011; Kenny et al., 2014; Burin et al., 2019). Musicians invest highly in their identity as performers and often struggle to disentangle their self-esteem from their musical competence – the perception that ‘failing’ in performance equates to failing as people increases performers’ vulnerability to anxiety (Sinden, 1999; Kenny, 2009).
	Negative affect	Studies have reported significant associations between negative affect and MPA (Zinn et al., 2000; Sadler and Miller, 2010), although the direction of this association is unclear.
	Neuroticism	Neuroticism and MPA are strongly associated (Valentine et al., 1995; Langendörfer et al., 2006; Thomas and Nettelbeck, 2014).
	Susceptibility to anxiety	Susceptibility to anxiety refers to an individual’s pattern of perceiving situations and anxiety symptoms as threatening or dangerous, and is a significant predictor of MPA, especially among women (Stephenson and Quarrier, 2005; Kenny, 2011; Burin and Osório, 2017).
	Trait anxiety	Anxiety is universally conceptualized as two-dimensional, comprising both state and trait elements – state anxiety is defined as a transient emotional state characterized by nervousness, apprehension, stress and heightened tension, whereas trait anxiety is a relatively stable personality characteristic whereby individuals tend to perceive situations as threatening (Spielberger, 2013; Brugués, 2019). The two dimensions are not independent – trait anxiety intensifies state anxiety and high trait anxiety predicts high state anxiety (Hamann, 1985; Kenny, 2011; Rumsey, 2015). Numerous studies report significant associations between trait anxiety and MPA (Hamann, 1982; Craske and Craig, 1984; Steptoe and Fidler, 1987; Lehrer et al., 1990; Cox and Kenardy, 1993; Kenny, 2004; Langendörfer et al., 2006; Burin et al., 2019) with some studies concluding trait anxiety is one of the strongest predictors of MPA (Smith and Rickard, 2004; Osborne and Kenny, 2008; Thomas and Nettelbeck, 2014). In their study of MPA and its anxiety correlates, Wiedemann et al. (2021) found Generalized Anxiety Disorder (GAD) to be the strongest predictor of MPA. One study seeking to explain the relationship between trait anxiety and MPA found that lower trait anxiety was positively correlated with participants perceiving their anxiety symptoms as non-detrimental to performance quality (Cox and Kenardy, 1993). Ruggiero (2012) found A-trait to be the only significant predictor of performance difficulties (self-reported), once gender had been controlled for. As well as predicting MPA, A-trait has been found to moderate the interaction between A-state and performance-related behavioral outcomes. Reducing trait anxiety could have real implications for managing MPA.
Cognitive style	Negative cognitions/cognitive style	Cognition arguably forms MPA’s primary component, with negative cognitions predicting MPA more than physiological, emotional or behavioral components (Miller and Chesky, 2004; Kenny, 2006). Studies show significant differences in the cognitions and cognitive styles of highly anxious, compared to low anxious, musicians (Burin and Osório, 2017), with maladaptive cognitive styles contributing to the development and sustenance of MPA (Osborne and Kenny, 2008). The cognitions of anxious musicians can be characterized by recurrent thoughts about negative past performances, imagined avoidance behavior, excessive focus on physiological cues, worrying about not being able to manage physiological arousal or manage negative thoughts, strongly negative self-evaluative focus, irrational beliefs (such as “I must be perfect”), expectations of negative evaluation from others, preoccupation with the consequences of suboptimal performances, catastrophizing, inability to manage negative cognitions (self-talk), perceptions of performances as threatening, and general worries about performing (Fehm and Schmidt, 2006; Clark et al., 2014; Kenny et al., 2014; Burin et al., 2019). According to one study (Lehrer et al., 1990), worry is the cognitive factor most significantly correlated with debilitating MPA. The diversion of mental energy to worrying is closely linked to disruption of attention from performance-related tasks (Osborne and Kenny, 2008); distraction and inability to focus are frequently cited as major sources of MPA (Steptoe, 1982; Grindea, 1984; Reubart, 1985; Talbot-Honeck, 1994). Conversely, positive (or realistic) thinking and MPA are negatively correlated (Steptoe and Fidler, 1987; Clark, 1989). Multiple regression analyses of MPA’s correlates showed cognitive factors to be the key predictor of MPA as they underpin all the other factors correlated with MPA in bivariate statistical analysis (catastrophizing, low self-esteem, low self-efficacy, trait anxiety, and maladaptive perfectionism) (Liston et al., 2003).
	Rumination	Negative post-event rumination (PER) is associated with increased MPA levels and decreased enjoyment of performance, with PER decreasing less quickly post-performance in high anxious compared to low anxious participants (Nielsen et al., 2018). Little research has been conducted investigating the relationship between PER and MPA, but these findings are consistent with research on general anxiety and indicate the association between PER and general anxiety.
	Judgmental attitude	Excessive self-criticism in practice and on stage, as well as absolutist judgments regarding one’s behavior, can predict and exacerbate MPA (Lehrer et al., 1990; Sternbach, 2008).
	Catastrophizing	Catastrophizing is a key predictor of MPA (Steptoe and Fidler, 1987; Zinn et al., 2000), with one study finding it to be the single most powerful predicting variable (Liston et al., 2003). While catastrophizing self-statements correlate with high MPA, realistic cognitive self-statements and appraisal of performance correlate with medium levels of MPA (Steptoe and Fidler, 1987), indicating the importance of self-talk.
	Fear of negative evaluation	Fear of negative evaluation (the disapproval of peers, teachers, colleagues, audiences and critics) is a core component of, and significantly predicts, MPA (Papageorgi et al., 2010; Nicholson et al., 2015; Kantor-Martynuska et al., 2018; Burin et al., 2019; Zhukov, 2019). Studies show increased MPA in evaluative versus non-evaluative performing situations (Kobori et al., 2011; Mitchell, 2011), which is problematic given the evaluative nature of professional music-making.
Comorbidities	Psychological issues	Research indicates that musicians’ mental health is an issue of serious concern – studies show that musicians report significantly higher levels of anxiety and depression than the general population (Barbar et al., 2014; Kenny et al., 2014). According to their study of over 2000 UK-based musicians, 71.1% of respondents had experienced panic attacks and/or serious anxiety and 68.5% reported depression (Gross and Musgrave, 2016). The majority of survey respondents ranged between 18–35 years, indicating the scale of the problem among the next generation of musicians. Studies consistently show significant correlations between MPA and a range of psychological challenges including depression, generalized anxiety, stress and substance abuse (alcohol and non-prescription drugs) (Vervainioti and Alexopoulos, 2015; Gross and Musgrave, 2016; Wiedemann et al., 2021). Musicians experiencing high levels of MPA are statistically more likely to experience these comorbid challenges (Burin et al., 2019).
	Physical issues	Research indicates that 55–86% of musicians experience playing-related physical problems severe enough to affect their performance (Kenny et al., 2016; Burin and Osório, 2017; Gembris et al., 2018). These challenges include headaches and stomachaches (Kivimäki and Jokinen, 1994), fatigue and sleep disturbances (Halleland et al., 2009; Dobson, 2011; Voltmer et al., 2012), chronic back pain (Brandfonbrener, 1986), peripheral nerve problems (e.g., focal dystonia) (Schuele and Lederman, 2004), hearing impairment (tinnitus/hearing loss) (Brandfonbrener, 1986; Harper, 2002; Gembris et al., 2018; Topoğlu et al., 2018), and Performance-Related Musculoskeletal Disorders (PMRDs), arising from excessive training, repetition and fatigue and manifesting in pain, numbness, tingling, weakness and other symptoms which disturb high-level performance (Schuele and Lederman, 2004; Voltmer et al., 2012; Vervainioti and Alexopoulos, 2015; Gross and Musgrave, 2016; Topoğlu et al., 2018). The MPA-pain relationship could be explained by performers experiencing psychological distress in response to injuries (Spahn, 2002), that fewer symptoms of pain and fatigue predict higher quality practice and performance (Kreutz et al., 2008; Ginsborg et al., 2009) or that the physiological dimension of MPA causes muscular tension, overstressing the body’s locomotor system causing overuse injuries (Hildebrandt et al., 2012; Rumsey, 2015). Physical challenges are often rated as a cause of MPA by performers (Burin et al., 2019).