Until recently, music performance anxiety (MPA) has been understood as a uni-dimensional construct occurring on a continuum of severity from career stress at the low end, to stage fright at the high end [1]. Kenny [2] has argued that MPA is better understood as a typology comprising three subtypes to account for qualitative differences in presentation as well as variations in severity. The three subtypes are: (i) MPA as a focal anxiety, where there is no generalized social anxiety, depression or panic; (ii) MPA with other social anxieties; and (iii) MPA with panic and depression. There are different levels of severity within each subtype. The theoretical model underpinning this typology is that MPA represents an intersection between an individual’s developmental history, which may be more or less disturbed – mildly, or not at all, in the case of focal anxiety and more severely in the third subtype - and the specific psychosocial conditions of musicianship - talent, achievement of technical mastery, preparedness, performance demands, exposure, competitiveness, and so on. Accordingly, MPA will have some of the general characteristics of other psychological disorders, in particular, anxiety disorders, which are shared by nonmusicians, and some that are specific to MPA and other performing artists such as dancers, actors, and athletes. This conceptualization of performance anxiety awaits further empirical examination. The aim of this paper is to contribute to a better representation and understanding of the third proposed subtype of MPA.

Attachment theory [3,4] offers a heuristic, evidence-based framework from which to explore severe performance anxiety in professional musicians. Attachment is defined as a biologically based motivational-behavioural system whose primary goal is to ensure survival of the helpless infant. This system is characterized by three features: (i) maintenance of the infant’s physical proximity to its caregiver through crying, clinging, crawling, searching and reaching for the attachment figure to attain physical closeness; (ii) using the attachment figure as a “secure base” [3] from which to explore the environment; and (iii) returning to the primary attachment figure (usually the mother) as a “safe haven” when in danger or alarmed [2,5]. Bowlby [6] later expanded his view of the role of attachment to include reassurance of the ongoing (emotional) availability of the caregiver, experienced as “felt security” (defined as a subjective or internal experience of comfort and safety [7,8] recently redefined as ‘epistemic trust’ [9].

Four main patterns of attachment have been identified [3,10]. First, securely attached infants, with attuned and responsive caregivers develop felt security. Insecure infant-parent dyads fall into three types: (i) In avoidant or ‘deactivating’ attachment [11], infants appear calm and independent and more interested in exploring the environment than communicating with their caregiver. Despite the apparent lack of manifest distress, these infants have elevated heart rates and levels of circulating cortisol (stress hormone) [12]. These babies learn that attempts to seek comfort and care from their mothers are likely to be met with rebuff, and therefore develop self-sufficiency; (ii) In ambivalent or ‘hyper-activating’ attachment, infants exposed to inconsistent and intermittent care are too concerned about their mothers’ whereabouts to feel free to explore their environment. They respond with intense distress when left, and appear inconsolable when reunited [11]; (iii) In disorganized attachment, that presages later psychopathology, infants have experienced ‘frightened and/or frightening’ care givers [13] and are thus subject to an ‘approach-avoidance dilemma’ in which the source of comfort is also a potential threat, either through neglect or active physical or sexual harm from parents who are mentally ill, substance affected or chronically depressed or anxious [14]. Following reunion after separation, disorganized infants may manifest this conflict through seemingly inexplicable and bizarre behaviours, which may have a ‘perverse’ self-soothing component, that include ‘freezing’, collapsing to the floor, and appearing dazed and confused.

The development of these varying attachment patterns – which also have a severity as well as a categorical dimension [15] - is an interpersonal process that emerges in the context of the parents’ care giving style. Parental states of mind are typically assessed using the Adult Attachment Interview (AAI) [16]. Secure mothers tend to have secure infants who grow to be secure adults. Parents of avoidant infants tend towards dismissing states of mind: they minimize or devalue the influence of their own attachment experiences, and ignore or suppress their infants’ attachment needs, who in turn, learn to minimize their own needs, becoming compulsively self-reliant, and reluctant to feel or express emotions. Such parents, however, tend to display excessive physiological arousal, as do their avoidant infants [17]. Parents of ambivalent infants have ‘preoccupied’ states of mind [14], so called because past unsatisfactory attachment experiences intrude upon their present life and relationships. The emotional life of such parents is governed by feelings of helplessness and fears of abandonment, disapproval or rejection; hence, they are often discouraging of their child’s growing autonomy. In contrast to avoidant infants, ambivalent infants use hyper-activating strategies that amplify their affect in an attempt to secure the attention of their unreliably available parents. Finally, parents of disorganized/unresolved infants have often suffered repeated trauma in their own developmental histories, and are classified as ‘unresolved’ on the AAI. Responses to unresolved trauma include fear, emotional withdrawal, and dissociation.

A number of brain structures are involved in regulating the brain’s danger response system, including the amygdala, mature at birth, which is involved in the fight/flight response, and where, it is hypothesized, unconscious emotional memories are encoded; and the later maturing hippocampus, which moderates the reactions of the amygdala and interacts with the cortex to store explicit, linguistically retrievable memories [18]. In children who have suffered severe emotional or relational trauma, the development of these brain structures may be compromised, with the result that the unchecked reactivity of the amygdala will produce extremely intense autonomic reactions in response to relatively minor internal or external triggers [19]. The extreme reactions of intense music performance anxiety in some musicians can perhaps be understood in this context. Kenny [2] has hypothesized that severely performance anxious individuals, by virtue of faulty attachment experiences in early life, do not develop a sense of felt security on which to draw when endangered on stage.

The attachment system remains active during adulthood and continues to exert a significant influence on psychological and social functioning. Adults respond to perceived threats with activation of the mental representations of attachment figures laid down in infancy and childhood, as a means of coping and regulating emotions [20]. When these attachment systems are insecure, especially if disorganized, their activation at times of stress and crisis is likely to result in emotional dysregulation. This provides a plausible model for the type of emotional difficulties experienced by musicians whose music performance anxiety feels unmanageable. Individuals with developmental histories leading to patterns of severe insecure attachment cannot readily mitigate distress or attain felt security. Instead, in the face of intense distress, alternative, secondary attachment strategies involving either hyperactivation or deactivation of the attachment system are triggered [14]. By contrast, those who are securely attached demonstrate both a strong sense that they can manage the threat and, if need be, seek support from others to aid their own coping efforts [21].

In light of the above discussion, we examined an account of severe music performance anxiety from a professional musician who participated in a phenomenologically-oriented, open-ended, in-depth interview. The account given below elaborates the narrative which emerged in the course of the interview.

Participant

Callum, aged 26, a pop musician and his band’s lead singer and song-writer, comes from a somewhat conservative, professional family. His father is an ear, nose and throat (ENT) specialist, his mother is an academic; he has two older brothers in the legal profession. Callum is the youngest, and definitely the “black sheep.” He stated that he always felt “like a misfit” in his “academic” family and like “an antipathy” in his private school. He described his family as “streamlined” by which he meant that they had all trodden the familiar path of school, university, profession, partner, marriage, and children. He said that he “went through a process of separating myself from all that life.”

He presented in Bohemian/Indian dress with dreadlocks, headscarves, and numerous body piercings. He lives an alternative lifestyle in the “arty” side of town because he does not “feel so much like an alien” there, although he struggles to manage on his insecure income and casual work (“I do not exist within that social framework of 9 to 5, Monday to Friday”). To supplement his income from “gigs”, he works part-time as a barista to pay the rent. Callum experienced some learning difficulties at school and did not complete any formal secondary qualification, preferring to pursue his desire to become a professional musician and songwriter. At 15 years of age, he “decided not to take any more money from my parents because in order for me to feel valid in this world I need to make my own way.”

Callum was encouraged to participate by his father, who was worried about Callum’s concerns with his voice, for which no physical cause could be identified, his increasingly withdrawn demeanour, and his dishevelled appearance.

This case report was part of a much larger interview-based study of performance anxious musicians that was approved by the University of Sydney Human Ethics Committee. The first author conducted the interview, which was audio-recorded and fully transcribed with the written consent of the participant. Two reviewers (i.e., the two authors), both experienced clinicians in attachment-informed psychotherapy, independently analyzed the transcript for themes and content, as well as for the presence of exemplars of the theoretical constructs under investigation (i.e., quality and type of attachment experience in early life).

Interview format and analysis

Psychoanalytic psychotherapy reconstructs the stories an individual tells about him- or herself through a process of narrativization of an experience, or ‘keeping a particular narrative going’ [22] that would otherwise ‘linger as a traumatic lapse of meaning’ [23]; that is, it offers a ‘home’ for meaning, which is a precondition for psychological well-being. In attachment terms, the interviewer aims to develop a relationship of sufficient security and ‘epistemic trust’ for the interviewee to feel free to explore the emotional truths of his or her life-story. Hence, a qualitative life story method supporting a holistic, contextualized, chronological telling was used in this study, a method akin to history-taking methods in psychotherapy [24].

There are a number of significant precedents for the use of narrative data in studies that explore the role of psychological factors in health outcomes. One such example is a 35-year longitudinal study of male physicians that revealed the impact of a pessimistic explanatory style, assessed via narratives of participants’ life experiences, in increasing the likelihood of negative medical outcomes [25]. Conversely, a 60- year longitudinal study of nuns found the expression of positive affect in unstructured narratives in early adulthood to be a predictor of longevity, with those with positive affect surviving those with negative affect by an average of 10.5 years [26]. Cousineau and Shedler [27] argued that narratives “tap implicit psychological processes not accessible via self-report questionnaires” (p. 428) because participants lack conscious awareness of such processes (hence their implicitness), or may be unable or unwilling to disclose such processes directly, even if they are aware of them. Many individuals defensively deny, avoid or downplay emotional distress and musicians are no exception. Shedler, Mayman and Manis [28] called this defensive denial of distress, aroused via early memory narratives, “illusionary mental health” (p. 1117) and found strong associations between denial and physiological reactivity. Levitt [29] has noted the expanding and increasingly accepted use of qualitative methods in psychotherapy research, because it “provides a vivid, dense and full description in the natural language of the phenomenon under study” [30].

For the purposes of this study, the transcript commences at the point where Callum is asked: “Can you tell me what it is that has been concerning you about your musical performance?” Callum needed very little encouragement to speak. Accordingly, subsequent interviewer participation was minimal and comprised simple encouragers (Mmmm, ah-huh etc.), clarifying comments (“It sounds like…”; “Can you say more about that?”) and an occasional question that assisted the interviewee to further explore his understanding of his relationship with himself and his music (e.g. “What are the worst manifestations of your music performance anxiety?”). The questions, comments and interpretations (hypothesis-testing) arose organically from the interaction between interviewer and interviewee for the purpose of clarification, confirmation of understanding, or to explore hypotheses that arose in the course of the interview (e.g., “Do you have trouble having faith in yourself in other endeavours or is it mainly focused on your musical performance?”).

Textual and thematic analyses of this phenomenologically-oriented narrative were undertaken, based on the text and the independently derived commentaries of the two clinician assessors. The research process was informed by McLeod’s [31] five stages of qualitative data analysis – immersion, categorization, phenomenological reduction, triangulation and interpretation. The analysis of the transcript was guided by the methods of consensual qualitative research (CQR) [30]. The commentary on the narrative represents the triangulation and consensus interpretation of the two reviewers.

Below is the verbatim narrative derived from the section of the interview related to Callum’s music performance anxiety, with some narrative smoothing at points marked (…) that were considered unimportant or repetitive and omissions of words or phrases at points marked […] to conceal personally identifying information.

Recently, I’ve started having panic attacks... in the time leading up to a gig, I start to feel very separated and vague; my body is just reacting and I’m not quite there. It’s a really bizarre feeling and difficult to put into words … When I’m under pressure I feel really vague. I start to question…everything surrounding me and I … get into this philosophical downward spiral…Then I get a brain fog. When I know I’ve reached this point where I’m severely anxious, I get these cold flushes through my hands… For the past two years I get extremely anxious for a few weeks, and it’s like a constant state of anxiety for those few weeks, and then it passes… Relating to music, specifically last year, I was in a band that was doing a lot of really good gigs and I was at the centre of it. I was writing the music; I was organising it all. It was a seven piece band with some really good musicians. I’d been overseas for four years travelling, and I got back at the beginning of last year - and suddenly I was confronted with having to be in some sort of musical framework and structure from week to week being at rehearsals and voice being in good condition and I just went into overload. Writing (songs) and having all the stresses that you would have, trying to lead a normal life, waking up early, being concerned about the amount of sleep I was getting.

And on top of it all, my voice just shat itself. It began to freak out. That was the way that my anxiety decided to express itself, through my voice because I was the most acutely aware of it on a day to day basis. I entered this spiral about it. My voice hasn’t always sounded husky like this. It is not as bad as this when I sing…There shouldn’t be a difference between your speaking voice and your singing voice; it is the same thing. But my singing voice isn’t like this. I manage to slip into a bit of a groove when I sing, and it’s different to my speaking voice. So that was all of last year - I had all the checks on more than one occasion. I’ve been to a variety of voice and ENT specialists and had laryngoscopies a bunch of times. The first doctor that I went to said, “Yep, you’ve got polyps, we’ve got to get them removed.” Then my dad, who is an ENT specialist, said “Let’s just go for a second opinion.” So I went to a different ENT doctor. He said, “No, there’s nothing there.” Since then, stories have surfaced about the first ENT. A couple of singers have told us they are bringing a case against him because he’s prescribing surgery for people who don’t need it - people in serious situations, such as professional vocalists...

Anyway, so this was just an absolute roller coaster, as you can imagine. I’m trying to front more than one band. I was in three bands at the time as well…On top of it all I was coming back from India as well; I’d been overseas for a few years and I was thinking this was all intertwined and at the root of it all, everybody is telling me there is nothing wrong with my voice. And I’m going, “Well, what do I do here?” Sometimes I find it difficult to talk when I’m anxious, and it’s not like a thinking thing. I actually have trouble getting the words out.

Late last year I lost one of my closest friends; she died suddenly and it was around that time that I entered a really severe depression. There were a lot of heavy things happening and I was feeling an immense pressure on my shoulders about this musical thing. I had this amazing band… everyone in the band was saying to me, “You’ve got talent, everything is great. You’re a great songwriter. You’re a great front man. Everything is great.” But I just was systematically undoing it in my head. I just really lost faith in it all. And then this happened… my friend was travelling on a bus through […] and her body just decided that’s it, and she just died. We’d met in India and travelled together for a couple of years. I’d lived with her in […] and there was a romance… the timing was never right but one day we said we would revisit it. Then she died… that’s the bizarre thing about travel relationships - you develop these intense relationships that nobody else in the world knows about…

Then I entered… the most severe depression I’ve ever entered in my life. I woke up in the morning, found no reason to get out of bed… and …considered suicide … I never actually – I was never there, never thinking to myself, “Okay, I’m going to commit suicide” but …just considering the whole meaning of it all… I never felt like I was actually going to go through with it – it was more realising that all the things that I loved in my life were coming down around me and if I can’t sing and I can’t write music then what have I got to live for? …I had all these things that were coming up on a personal level; singing, being in a band, boiling over and then my friend died and that toppled me over the edge. All the water overflowed out of the pot.

Since then, the really serious band that I was in came apart and we unofficially broke up at the end of last year… I place the responsibility solely on myself - I brought my personal issues into the band, and I would turn up to rehearsal and not physically be able to sing, like not be able to get notes out of my mouth… and it became infectious, because nobody wanted to be in that environment, where there was no creativity and there was a really bad vibe around.

In the last six months… I’ve done a full circle. I took a solid few months off gigging. I was writing music. I tried to get the band back together once or twice but it just never happened…There’s a couple of guys in that band who are professional musicians, and that always really intimidated me because they would always put me in a situation where I didn’t feel like I belonged there. I didn’t feel like I was legitimate – I didn’t feel like I had earned my right to be there. I was saying to myself, ‘Why do these really great musicians want to play with me?’ They believed in me but I just butchered it… I’m not good enough. Why are these guys wanting me… they were getting us really good gigs … but I just didn’t believe in it. I thought, ‘As if these guys want to play music with me.’ I had really no faith in myself.

Callum described an array of distressing symptoms [feeling “separated and vague;” (dissociation); “my body is just reacting and I’m not quite there” (depersonalization/ disembodiment), “brain fog” (cognitive perceptual disruption); and “cold flushes through my hands” (motor conversion)] which we may conclude are symptoms of panic attacks/dissociative episodes. He talked of going into “overload” and described how he tried to cope with feeling overwhelmed and uncontained by “trying to lead a normal life…getting enough sleep.” Callum also reported “…find [ing] it difficult to talk… to get the words out” (somatization), and feeling “immense pressure on my shoulders (striated muscle tension).” …In short, he was on an “absolute rollercoaster.”

This symptom complex suggests the presence of extreme anxiety in someone who does not have a reliable secure base. Callum’s anxiety, generated by repressed emotion, manifested in all four ways described by Abbass, Town, and Driessen and Davanloo [32,33]: (i) tension in the striated muscles of the body; (ii) smooth muscle anxiety that manifests as somatising illnesses; (iii) cognitive perceptual disruption (CPD) that manifests as confusion, blanking out, tunnel vision, blurred vision, ringing or buzzing in the ears, and dizziness and fainting; and (iv) motor conversion, which manifests as unexplained weakness or other physiologically inexplicable symptoms in the limbs and psychogenic voice disorders, among others [34].

Callum described multiple losses and betrayals of important attachment figures – perhaps his mother, who was conspicuous by her absence in his narrative, his father who appeared concerned but avoidant in his attachment style, the ENT specialist who was prepared to exploit him, his band, which he experienced as a secondary secure base that “came apart”, and his lost lover whose death “…toppled [him] over the edge. All the water overflowed out of the pot… All the things that I loved in my life were coming down around me.” Callum is here describing the absence of a secure base or felt security within – the whole edifice of his fragile internal objects was imploding. Profound internal emotional conflicts rendered him speechless and voiceless. He could not speak and he could not sing –“…and if I can’t sing and I can’t write music then what have I got to live for?” He reported suicidal ideation. He felt trapped in a silent nightmare. Anxiety was the iceberg tip beneath which lay repressed rage, guilt and grief about early attachment ruptures that were re-triggered in his current life by the losses of his voice, his creative drive, his band, and his “travel lover”.

Most of his concerns were, however, centred on his voice. “I’d wake up in the morning and the first thought was, how is my voice feeling today?” Despite the care he exercised, his “voice just shat itself. It began to freak out. That was the way that my anxiety decided to express itself, through my voice because I was the most acutely aware of it on a day to day basis.” Callum’s state of disorganized attachment was embodied in his voice, which was both the nurturer/giver and the tormenter/ withholder.

Callum’s preoccupation with his voice and his throat could also be seen to represent a bid for his father’s attention. His father responded to Callum’s distress in an ‘organised insecurity’ (typically avoidant) fashion [7], i.e., he was to an extent ‘there’, taking his son to an ENT surgeon, but perhaps in an emotionally distant and somatising way. He was unable to respond to his son’s emotional distress. The very part of himself that Callum wanted his father to love and validate was also the part that both manifested his vulnerability, and perhaps too, like the inconsolably crying infant, wanted to attack and debase and baffle his father in protest at his father’s emotional unresponsiveness.

Callum’s talent and creativity, as often found in creative artists, were both a manifestation of, and an attempt to transcend core psychological themes. By writing and performing, he attracted the attention of ‘The Other’, but was then beset by doubts as to whether he had sufficient talent, whether other professional musicians wanted to work with him, and whether he would be accepted with all his vulnerabilities. Callum’s internal disorganised despair sabotaged him – despite some “really great musicians want [ing] to play with [him], Callum did not feel “… legitimate… I didn’t feel like had earned my right to be there… I was systematically undoing it in my head…they really believed in me but I just butchered it…I really had no faith in myself.” Here is another brutal image through which Callum described how he destroyed any good feeling or belief in his talent; he infused their “good” words with his badness, which became “infectious… there was really a bad vibe around…I place the responsibility solely on myself” (persecutory selfobject). [Note: In disorganised attachment the child has no-one to ‘metabolise’ his vulnerability and helplessness, so ‘bad’ feelings cannot be detoxified and remain within the ambit of the self].

The fear of being an impostor, a fraud or a sham is very common in anxious musicians and this is certainly a sentiment expressed by Callum. Children of highly critical/accomplished parents may come to believe that regardless of their achievements, they will never meet the standard expected. The pervasive message is that one is either never good enough or is only good enough if meeting parental expectations, rather than one’s own. Callum was perhaps a poor fit in his family of conservative, high achievers. Being the youngest, he may have concluded early that he could never measure up to his older brothers or his parents, so he attempted to carve out a very different path for himself. Sadly, the feeling of being a fraud followed him - he could never be good enough, no matter what he did [2].

At this point in his life, Callum was unable to contain his anxiety and hopelessness, or the rage and grief that were threatening to break through (suggested in his savage imagery and choice of words such as “shat itself” “I butchered it”); these “bad” feelings started to overflow and spill out in all directions – his music, his personal relationships, his position in his band, and his relationship with himself, his creativity and his voice. This narrative provides evidence for the presence of a significant depressive illness, with anxiety as one of its manifestations; others include sleep disturbance, identity disturbance, negative thoughts and ruminations, difficulty getting out of bed, and suicidality.

The use of stories or narratives and case histories as “evidence” in psychotherapy are criticised on the grounds that using the case history as ‘data’ involves an unconscious and preconscious narrative smoothing on the part of both teller (patient) and listener (therapist) [35]. Analyses of text may be biased in the direction of the theoretical frame under which the narrator/therapist operates. However, these are not insurmountable hurdles. Safeguards include recording and verbatim transcription so that there is a complete record of the interview, the use of independent assessors of the narratives, and the development of case formulations from different perspectives. These safeguards were to an extent applied in this study, in that the independent assessors reached their formulations independently – and, as it happens, transcontinentally! They were only cross-checked and discussed post-formulation.

The psychological equivalent of the physical response to life threatening situations - tonic immobility or “playing dead” - is dissociation. Emotions are, in the first instance, bodily experiences. Through the sensitively attuned attachment relationship emotions are modulated, regulated, and understood. When such a relationship is absent or impaired, so too is the capacity for emotional regulation, including the capacity to accurately identify, name and understand emotional experience - a phenomenon theorized by Fonagy and colleagues [36] under the rubric of ‘mentalization’. To the extent that mentalizing is de-activated or undeveloped, emotions are manifest as somatic sensations or physical symptoms that are never fully comprehensible to the person experiencing these states. Emotional experiences that are too painful or traumatic, or are judged to be unacceptable to the primary attachment figure, will be split off in this way, remaining dissociated, undeveloped and stored somatically [37].

Individuals whose early attachment experiences were unsatisfactory tend to experience rapid shifts of feeling from manageable to overwhelming states of mind. Suboptimal attachment relationships can undermine the development of cortical structures that are associated with both affect regulation and mentalization. This may result in chronic hyper-arousal, such as that seen in severe anxiety, including severe music performance anxiety, which cannot be modulated by mentalizing or seeking comfort from an attachment figure [38]. Such hyper-arousal is experienced as outside one’s control: disturbed attachment experiences result in the lack of a stable sense of self (internal secure base) with the capacity for symbolic representation of one’s own mental states, especially negative ones. These include, for musicians, physical pain or disability, rivalry and a sense of failure, disappointment, and lack of adulatory audience response, among others. Hence, affect remains intense, confusing, poorly labelled or understood and above all, unregulated.

Many of these elements were evident in Callum’s narrative. By all accounts, Callum was musically gifted. Musical talent is good for one’s self-esteem, but if the totality of one’s self-esteem is bound up with being a ‘good’ performer it can become persecutory – to play or sing badly is to be a ‘bad’ person. Callum felt globally ‘bad’ – this was the essence of his depressive anxiety. He accepted the responsibility not only for his voice “shitting” itself, but for the dissolution of the band, into which he believed he had injected “bad vibes.” At times of intense anxiety, he described chronic hyper-arousal comprising physical, sensory and dissociative symptoms that were poorly mentalized. He tended to turn the blame exclusively onto himself, perhaps to protect his attachment figures – his father, his band mates – from his developmentally-derived rage and censure.

Self-monitoring (i.e., observing oneself, learning from and correcting mistakes) is a necessary component for skill-acquisition, and is essential in the performing arts. However, this self-monitoring process can also become persecutory. Internal relational models from childhood will colour current conflicts, for example, the critical parent/ transgressing child dyad or the ‘bad’ parent (maybe representing a projection of the child’s anger)/victimised child dyad. Callum’s selfexperience was both transgressing and victimised – on the one hand, his woes were his fault; one the other, he implied that he had no control over his symptoms. It was his (disembodied) voice that “shat itself”; he did not do the shitting; his voice did it.

The aim of this paper was to illustrate the complex and multifaceted psychodynamics and therapeutic needs of musicians with insecure attachment and its possible relationship with how they express their music performance anxiety [39]. One of the key aspects from the musical point of view is the occurrence of physiological hyper-arousal in insecure attachment. To the extent that emotional energy is directed into “holding” oneself during a performance, the communicative process becomes impaired. Excessive self-awareness detracts from emotional expressiveness, resulting in less favourable audience response to the performance, which may arouse or exacerbate anxiety, creating an escalating vicious circle. In the event that musicians do not seek psychological assistance, they may resort to alcohol or drugs, prescribed or otherwise, sexual escape or leaving the profession, either temporarily, as in Callum’s case, or permanently.

An awareness and understanding of the role and function of attachment theory in understanding the severely performance anxious musician has, we hope, been demonstrated through this case study report. Additional published cases will further clarify the psychodynamics of severe music performance anxiety, identify suitable treatments, and hopefully relieve the intense suffering of this group of musicians.