On Focal Dystonia (3b)

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Psychological Aspects of FD

Many recent studies on musician’s dystonia now acknowledge the role of psychological and emotional factors contributing to the emergence or persistence of the disorder. In the previous section, I have already alluded to one of these psychological pressures: the need or expectation for perfection in classical music training. Indeed, this point has been emphasised many times across many research papers, including several by Altenmüller and his colleagues. For example, Altenmüller & Jabusch (2009) is a noteworthy paper, as it compares psychological profiles (“personality structures” is one of the terms used in the paper) of patients with FD and those without. Interestingly, a group of patients suffering from chronic pain was also examined, with the aim of “detect[ing] unspecific secondary psychological reactions in diseased musicians.” I object slightly to the use of the term “diseased”, but you get the idea!

The results of the study are quite clear: anxiety disorders and social phobias were more prevalent in patients with FD than in healthy musicians (hereafter HM). Although patients suffering from chronic pain also showed different psychological patterns from HM, in general they recorded scores between those of the other two groups. In particular, and most significantly, FD patients showed a pattern of “exaggerated perfectionism” not seen in patients with chronic pain nor in HM. This raises the important question — whether pre-existing anxiety and perfectionism contributes to FD, or whether these characteristics are “psychoreactive symptoms” of the playing disorder. Based on their data, the authors of the paper suggest that it is the former condition. Actually, this model of the development of FD reflects my own experience quite accurately. Let’s not forget that all performing musicians deal with stressful situations, the most obvious being performing on stage in front of an audience, and playing in an audition. For music students, there are also masterclasses, and necessary evils such as technical exams, jury recitals and competitions. Depending on your teacher’s personality, even studio classes and lessons can be stressful. Hence, it makes a lot of sense that musicians with elevated levels of anxiety and perfectionism are more at risk of developing FD. The emotional or affective component of music making cannot be ignored either. Performing a piece of music requires significant physical and emotional effort. Add perfectionism and anxiety into the mix, and you will have a very stressful experience indeed. Whether or not someone appears to be anxious or nervous is irrelevant. Those of you reading who are classical musicians (or actors, for that matter), I wonder how many of you have received comments such as “you didn’t look nervous at all!” I am always grateful for these comments, since they are invariably well intended, but it is really a meaningless statement. Of course we don’t look nervous — either we are genuinely not nervous (if you fall into this category, then I don’t believe you), or we are simply very good at managing our nerves. If we do our job properly, then we will have at least created the illusion of being in control and mastered our art! Unfortunately, we must accept that while the audience will (hopefully!) appreciate our brief time on stage, rarely will they stop to think of the hundreds of hours of painstaking preparation.

Perfectionism and FD are the ideal ‘frenemies’, so to speak. Classical musical training, with its emphasis on perfection, does nothing to alleviate this, and in fact feeds the vicious cycle. Sometimes, the demands can be absurd to an outsider. Take, for example, the violinist who proudly proclaims (well, roughly speaking) “I spent 3 hours on the first page of the Mendelssohn Violin Concerto today!” Or just point out a split note to a horn player — which I imagine is a great way to never make any horn-playing friends. A perfectionist will fixate on the smallest of details, overthinking everything, but most importantly, be very irritated at any slight perturbation or deviation from the idealised ‘perfect’ performance. So imagine the hypothetical situation in which you are a very accomplished violinist working on the Sibelius Violin Concerto, one of the most demanding pieces in the entire repertoire. (If you are a violinist, then unfortunately for you, this may not be hypothetical!) There is a particular passage you are struggling with, but your perfectionist tendencies motivate you to practise this isolated passage obsessively, sometimes repeating it over the course of a full hour, breaking it up into little segments and practising all the individual changes of position and tricky bowing patterns. Altenmüller and Jabusch suggest that “musicians with an inclination toward anxiety and extreme perfectionism may emphasise the disturbing and threatening element in the occurred wrong movement.” In our hypothetical case, it is possible that the problem is quite simple (perhaps a change of fingering? conceptualising the shift differently?), but the poor violinist has exaggerated the significance of his lack of fluency in one particular passage, and reprimands him/herself for the ‘failure’ to execute this passage ‘perfectly’.

A newer study by Ioannou & Altenmüller (2014) builds up an even more detailed psychological profile of musicians with FD. In addition to the well-known traits of anxiety and perfectionism, the study investigates more specific factors including (but not limited to) the following:

• Self-doubt & personal standards
• Parental expectation & criticism
• Mental perseveration (*not a variation of “perseverance”, see the linked Wikipedia article for a quick definition)
• Self-incrimination

I believe this study shows that there is a complex interaction between pre-existing personality traits and environmental or occupational pressures. Among the patients with FD, the majority tended to score higher than healthy musicians for the parameters listed above, but there was also a minority who did not. The authors of this paper thus came up with the two classifications HPE (high psychological effects) and LPE (low psychological effects) to describe the two distinct ‘clusters’ of data, and furthermore postulated that the lack of a consistently effective treatment for FD may be due to the highly individualistic nature of the disorder. This is not exactly the good news a musician with FD would like to hear. For those with perfectionist tendencies, the situation plays all too directly to our main weakness: our usual self-doubts about our abilities become real, and we deteriorate from just thinking “I can’t do this” to being literally, physically unable to play. Worse still, the more we push ourselves to practice, the  worse the dystonic movements become. As classical musicians, who are accustomed to solving problems through disciplined practice, we feel suddenly faced with what seems to be an insurmountable obstacle.

Although it seems we are still a long way from any definitive cure — if such a thing is even possible — fortunately there is now more information and help available for musicians with FD than ever before. Many have realised that the key to overcoming the disorder lies within a biological organ so remarkably complex it can hardly understand itself: our own brain.

—> to Conclusion