Psychology of Music Essay:

Therapeutic Music: The effects of music in stress and pain, a

psychological and physiological perspective

author:Tsiplakos Konstantinos
student number:s1473657

Introduction
"Music is ubiquitous, emotional, engaging, distracting, physical, ambiguous, social,
communicative, it affects behaviour and identities" (McDonald, R. et al. 2012). It is a
global phenomenon and it is a big part of humanity's every-day experience, regardless
of age, race, sex or ethnicity. It can have an effect to the whole person, including
body, heart mind and soul like "a mysterious artery" (Munro, 1999, p. 121). Therefore
it is not surprising that music can affect various aspects of a person's life, including
psychological stress and pain perception.
The therapeutic properties of music are known since the ancient times and a great
number of civilizations have used it as a therapeutic medium. (Gouk. P. 2003 and
Horden,P 2001) including Assyria, Rome, Greece, India, China and Egypt. Indeed, in
the days of Pythagoras cases of melancholia, lunacy or delirium were relieved but
listening to certain tonalities. The phrygian tonality was administered for bipolar
disorders, the Dorian to the maudlin and the Aeolian to the coward. Plato and
Aristotle thought that music could influence emotions in listeners. (Waterfield 1993
cited by Elliot,J. and Silverman,M. 2012) Early Greek physicians like Zenocrates and
Arien used harp music to reduce seizures. (Shapiro 1969 as cited in G. Bernatsky et
al. (2012) Music Health and Wellbeing Oxford University Press Chapter 19). During
the late Renaissance period, music was proven to halt convolution of the patients of St
Vitus fever. Furthermore, there are also records of famous psychopaths helped though
exposure to the music of vocalists, examples are Philip V of Spain, Ludwig of Bavaria
and George III of England. In post industrialization world, Florence Nightingale noted
the effects of different types of music while tending injured soldiers in Crimea during
the 19th century and music therapy was prominently used after World War II and the
return of veterans many of whom experiencing post-traumatic stress and injury related
chronic pain. (De LEtoile., S. 2012). In that cases music was used by doctors in
specialist hospitals for veterans as way of relieving acute pain and act in a positive
manner improve the quality of life. The practice continued with Vietnam veterans
experiencing PTSD (posttraumatic stress disorder) Burt, J. W. (1995). While the
historical findings lack the methodology and the robust research methods used by
modern scientists, and could be considered anecdotal, the fact remains that humanity
has a long held believe and practice in the soothing effects of music.
Hans Selye defined stress in 1956 as "the non-specific response of the body to any
demand for change" (Hans Selye, Stress of Life. McGraw-Hill1956.). Responses to
stress can be both psychological (anxiety, irritability) and physical (increased blood
pressure, difficult breathing, vertigo).
Pain on the other hand is defined as "An unpleasant sensory and emotional
experience associated with actual or potential tissue damage, or described in terms of
such damage." (International Association for the Study of Pain-IASP Taxonomy.
Web)

Stress and pain have shown to interact. Elevated pain levels lead to stress that makes
coping with the pain more difficult and stress before a painful procedure can affect the
pain perception and increase its effect and make the experience worse, especially in a
medical applications. Then the added pain leads to more stress and the whole thing
lead to a vicious circle that needs to be resolved, for it may "have a negative effect on
medical treatment" (Ralph Spintge 2012). Furthermore, evidence shows that stress
can have negative effect on a person's immune system.
Nowadays, music can act as a therapeutic medium that anyone can utilize, just by
listening to music at home, school or in a hospital but will have an even greater effect
if administrated by a professional trained in music therapy. "Music Therapy is the
clinical and evidence-based use of music interventions to accomplish individualized
goals within a therapeutic relationship by a credentialed professional who has
completed an approved music therapy program." ( source: American music therapy
association). Music therapy can take many forms from passive ,listening to a recorded
piece or a live music session to active, where the person participating plays or sings a
tune or improvisation sessions.
A very interesting area of work of music and music therapy is clinical environment
were stress factors and pain are more prominent for the patients than in their normal
life outside the hospital and reducing stress and pain levels without drugs are very
beneficial to patients and doctors alike. There are examples of routine procedures that
are made more difficult due to the stress and anxiety of the patient and of course postsurgery pain relief without the use of an extensive amount of medication that often
leads to side effects or even addiction is extremely beneficial to both parties. Music
therapy in hospices, places that offer palliative care to chronically ill patients is
another important area of study. where music is used in addition to other forms of
therapy to improve the patient's quality of life.
With the advancement of modern medicine there is a better understanding of what
happens inside a person's body. There is a wealth of amazing responses of the body to
music stimulus and therefore the exact physiological background of what happens
when someone listens to music can be hypothesized and perhaps even determined.
The effects of music have been observed to individuals regardless of age, sex, or
musical ability. Important facets of the work is research on infants and children who
have not developed the physiological and psychological shields to deal with pain On
the other side of the age spectrum, seniors frequently exhibit chronic pains and
neurological conditions where stress has a negative impact with stress (dementia) and
is important to find if music can provide relief to their conditions.
Finally, if indeed music is proven to be beneficial to a person's stress and pain
management as the historical evidence agree it is important to determine what kind of
music is best used for therapeutic reasons. Countless rhythmic, tonal and genre
varieties of music exist but whether they all work is something to be determined.

Music and physiology

While studying music and the body and mind's responses to it an important
parameter that needs to be examined is the limbic system, a collection of structures
including the hypothalamus, amygdala and hippocamus that are located in the brain
and are associated with emotional responses (Morgane P.J., et al. 2005) As it happens
the limbic system lies near the brain auditory cortex where all sounds including music
are processed. According to Thaut (1990), the feeling of pain also occurs in the limbic
system so when listening to music the signal reaches the auditory cortex and that in
turns sends a signal to various parts of the brain like the hypothalamus, thalamus,
amygdala and the brain releases endorphins and enkephalins to regulate feelings and
change the intensity of pain perception.
Music is thought to be perceived in the right hemisphere of the brain ("feeling") but
the left hemisphere ("thinking") may also take part in analyzing music components.
(Muskaja et al.2000). Later studies point to the fact that music influences several parts
of the brain including the primary and secondary regions in the cerebral cortex which
identifies audio or visual stimulus but also changes parts of the frontal and parietal
lobes as well. (E.Altenmuller and G. Schlaug (2012).The physiological effect of
music is also theorized to act from the hypothalamus that regulates various neurohormones.
Electroencephalography tests have shown that music can change the bioelectrical
signals of the brain. From beta waves (16-31hz) to theta waves (4-7Hz) and alpha
waves (8-15Hz). This can have effects like the reduction of anxiety and tension.
(Shawn 1999). and is a possible indicator of how music works to regulate stress and
pain.
Another theory is that music acts a distraction that focuses the attention of the
listener from negative stimulus such as pain and stress to something positive and
soothing like music and takes his mind off things. (Mok et al. 2003)
"The underlying assumption is that psychological processes associated with musical
experiences lead to changes in the hormonal system of brain and body" G.Kreutz et al
(2012). The interest in the relation between psychological and neurosomatic processes
of the individual has led to a new field of medicine called psychoneuroendocrinology
(PNE) that studies what hormone changes can do to human behavior. Several
hormones and "immunological markers" (G. Kreutz et al) of the human body have
been studied in relation with music.
Oxytocin, a hormone that has been named in layman's terms "hug hormone" or "love
hormone" because of the effect it has in our social behaviour. Nilsson (2009)
observed a rise in the levels of oxytocin in patients who had undergone open heart
surgery and were exposed to music compared to the control group. He noted a relation
between the relaxation of the patients and the increase in oxytocin levels of the music
group.

In the case of -endorphin, increased levels are linked with stress. Several studies
that used music in combination with physical exercise (Volleter et al. 2003) or
"guided imagery" (McKinney et al.) have shown consistent reduction to the hormone
levels while literature offers few examples of researches assessing only music without
combination with physical or imagination activities for a conclusive answer.
Cortisol, sometimes called the stress hormone has properties ranging from
controlling sugar levels in the body to influencing blood pressure and having antiinflammatory properties and is associated when changes of cortisol levels are
measured in the body. In one hand, several researcher that used "low-tempo"
(Yamamoto et al. 2007) or classical choral (Kreutz et al.2004) and folk music (Fukui
2003) in have been shown a decrease in cortisol levels and on the other hand techno,
upbeat pop and rock (Brownley et al. 1995) observed an increase in the same
hormone levels. Studies in hospital environment have shown a reduce in cortisol
levels in patients undergoing medical treatment after listening to music (Nilsson et
al.2005; Leardi et al. (2007)). Hisako Nakayama et al. (2009) studied the effect of live
music with ten cancer patients in a hospice. Cortisol levels were measured with a
saliva test to avoid the added stress of a blood sample to the patients and their mood
was assessed via questionnaires. A decrease in s-cortisol levels in all but one of the
participants along with increase in overall mood was observed in most of the cases.
Another study on patients during cerebral angiography (Schneider et al. 2001)
reported higher levels of both stress and plasma cortisol on the control group than the
music group where cortisol levels didn't change. Generally, there is good indication
measuring cortisol levels that music could have calming effects in individuals inside
and outside clinical environment and cortisol is considered a good indicator of stress
and is used in combination with questionnaires to quantitatively and objectively
evaluate the participant's stress levels.
Various other immunological markers have strong indications of positive responses
to music regarding pain and stress in a number of studies like adrenocorticotropic
hormone-ACTH, prolactin, serotonin, norepinephrine (Evers and Suhr
2000),corticotropin realeasing hormone (CRH), and Chromagranin A (CgA) (Suzuki
et al. 2004). ACTH in particular is linked with cortisol in the manner that when
someone is stressed, adrenocorticotropic hormone is increased leading to high serum
cortisol level (Morimoto 1997).

Music and pain

Pain, being an objective parameter and dependent on each person (i.e. what is
considered extremely painful for someone can be viewed as less painful for someone
else) and his psychological state (a sick, stressed, tired or anxious individual is likely
to experience more pain than a healthy, calm, rested one) can be measured by the
widely used Visual Analog Scale for Pain (VAS), the McGill Pain Questionnaire
(MPQ), Numeric Rating Scale for Pain (NRS Pain), Chronic Pain Gr ade Scale
(CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS) (G. Hawker et al. 2011).
These all are different forms of questionnaires that allow patients to describe the
felling and intensity of the pain they experience.
One of the earlier studies on the effects of Music in pain perception was by Gardner
et al. (1960). that focused on dental surgeries and effect of music or in some cases,
white noise which demonstrated that music helped relieve pain in 65% of the time and
allow a procedure without the use of anesthetic 25% of the time.
"Pain is still a major healthcare problem" (G.Bernatzky et al. 2012). Despite the
advancement of medicine and the discovery of new drugs , pain, especially
postoperative one is still a problem that need to be addressed. Even more, pain affects
a major percentage of the population. Breivik et al. (2006) conducted a large scale forty six thousand participants- survey in Europe where 19% of people reported
moderate to severe pain for at least six months while 40% of this group found their
treatment of pain inadequate. (cited by Mitchell, L. and MacDonald, R. 2012)
Music can supplement the effect of pain, anti-anxiety and stress drugs but can
sometimes perform even better and become a useful alternative for doctors. Bringman
et al. (2009) in a large (374 participants) randomized trial showed that the use of
relaxing music before an operation was more effective for lowering the stress levels
of patients than midazolam, a benzodiazepine drug with a number of side effects that
can be potentially dangerous especially in children, seniors and pregnant women.
A large number of studies collected in a Cochrane report by Cepeda et al. adding to a
total number of 3663 individuals experiencing postoperative to chronic, labour,
experimental pain showed that subjects who listened to music had reduced pain
intensity levels by more than 50% although Cepeda concludes that "the magnitude of
the benefits is small and the clinical importance still unclear". In other collective
work, Engwall and Duppils (2009) while reviewing almost a decade long of online
databases (1998-2007) found large indications of positive effect to postoperative pain.
Listening to music before an operation when patients' stress is naturally elevated in
anticipation of the procedure can have benefits as it can mask the unpleasant hospital
noise and help reduce stress and pain. (Heitz et al 1992;Cimmomgham et
al.1997;Spintge 2000).

A significant number of studies deal with the effects of music during a medical
operation (intraoperative). Balan et al. (2009) in a trial examining children's pain
during blood sampling divided them three groups, one taking a placebo, one listening
to Indian music and one using an anaesthetic cream with the pain scores of the
placebo group being higher than the other two. Several studies (Nilsson 2009,
Nilsson et al. 2005) and a review (Nilsson 2009) in patients listening to music during
cardiovascular and hernia operations reported a decrease in postoperative pain with
increased beneficial results in the cases of music therapy both during and after the
operation.
Music has shown to be effective even in patients under regional anaesthesia.
Tsuchiya et al (2003) made the proposition that it can be effective even under general
anaesthesia, since evidence suggests that hearing is maintained even when the patient
is unconscious. (Schwender et al 1993, 1994). However this hasn't been well
documented and not many studies exist to test the theory further.
Music therapy effects in pain are not limited to post-, intra- or preoperation
treatment. Studies on chronic pain and acute pain (Kullich et al. 2003) as well
chronic diseases like cancer (Kwekkeboom et al. 2009) and coronary heart disease
(Bradt and Dileo 2009) have been conducted revealing a positive influence ranging
from small to significant to pain perception in all the above cases.
An important result of music therapy besides reducing pain is the reduced need for
analgesics like opioids and benzodiazepines which are usually very strong, can have
numerous potential side effects and are not suited for long-term use. Studies from
Nilsson et al. (2009) with children, Ebneshahidi and Mohseni (2008) with mothers
after Caeserean section and Good and Ahn (2008) with women after gyneacological
surgery all reported a reduction in pain and analgesic consumption. Joyce et al. (2001)
studied the effects of recorded music played to neonates during circumcision
operation and the results showed that music had "comparable effects on pain
management with an analgesic dermal cream" (S. Koelsch and T. Stegemann, Music
Health and Wellbeing ch29, p448)
For example recent studies conducted with preterm infants (babies born before 37
gestational weeks) have shown improvement in both physiological outcomes like
heart rate, oxygen and blood pressure and signs of adverse psychological states like
crying, movement and facial expression and also an improvement in various pain
scores. (Chou LL et al 2003, Butt ML et al: 2000; Teckenberg et al 2010; There has
been also researches that point to positive effects of music on long term, like weight
gain and total length of hospitalization (J. Caine 1991). A review of several studies
were the participants were children aged 1month to 18 years by Klassen et al. (2008)
showed that music therapy "significantly reduced pain in children undergoing medical
procedures" (as cited by G.Bernatsky et al. in Music as Non-Pharmacological Pain
Management in Clinics. Music Health and Wellbeing, Oxford University Press,
Chapter 19 p 260) and can be seen as a supplement to medication.

Senior citizens listening to music experience a decrease in the perception of chronic

pain and stress related to age and neurological diseases (McCaffrey,R. et al. 2003).
Music has been used effectively as a form of treatment both at retirement centers and
at home. It can be noted that stress and anxiety contribute to dyspnea and dementia,
common issues amongst the elderly, and that chronic pain troubles a larger percentage
of senior citizens than the general population, thus making the use of music an
important tool towards the improvement of their lives. (Schmid, W. 2010)
To sum up, the use of music in clinical applications has shown consistent results in
increasing pain threshold and tolerance, providing relief from inflammatory pain,
reduce the need for preoperation medication by 50-100% and for postoperative
analgesic in addition to positive effect in numerous other physiological parameters
like decrease in blood pressure, heart rate, perspiration, muscle spasms, nausea and
insomnia which are beyond the focus of this review. (Ralph Spintge 2012)

Music and stress

Like pain, stress is considered objective and it's not a parameter that can be
measured in a single test. There are several ways of measuring stress and anxiety
levels. Questionnaires using the Likert Scale, hormone levels like cortisol, or StateTrait Anxiety Inventory (STAI), with the equivalent STAIC for children, the Visual
Analog Scale (VAS) and the Positive and Negative effect Schedule (PANAS) are
some of the common techniques utilized in literature. It is useful to note that like pain,
stress is an objective parameter and is perceived different by each individual that can
depend on personality, health and past experiences. (Sarason 1998).
As with pain, hospital and medical facilities are a great focus of recent researches.
Pothoulaki et al. (2008) conducted a trial on patients with renal failure undergoing
haemodialysis treatment. This particular treatment is frequent and lifelong for patients
with renal failure and the discomfort and complications that arise make the use of
anti-stress drugs and tranquilizers sometimes necessary especially for patients who
are not used to the procedure so it is evident that music therapy as an alternative or a
supplement would be beneficial in this case. In this trial the participants could choose
from a wide selection of music including Greek folk, popular, jazz and classical and
after the selection the patients favorite music was played from a CD player that they
could listen through headphones. The control group was free to continue their usual
activities during the procedure such as watching TV, reading a book or sleeping. The
results were positive in the effect of music in anxiety with a "significant difference"
between the control group and the music group. The music therapy group reported a
decrease state anxiety although no significant difference was found in pain intensity
between the two groups.

In a study with cancer patients using another form of music therapy, improvisation
(Pothoulaki,M. et al 2012) "five out of nine participants reported in their interview
that music therapy sessions were stress-relieving" among other positive results like
relaxation and increase in self-confidence.
Hunter et al. (2010) investigated music therapy with live music as a treatment of
stress for 61 patients weaned from mechanical ventilation. In this particular case, non
pharmacological stress management was even more important due to the fact that side
effects of the sedative include respiratory depression that adds further difficulties to
the weaning. In the self-reported results the patients observed decrease to stress levels
in the majority of the cases (80%) as well as a high percentage of patient satisfaction
(96%).
According to A. Short et al (2010), the hospitals themselves contribute to stress due
to a high noise level of the monitors, life support equipment, overhead lights, patient
sounds, visitors and medical procedures that one can experience even during
nighttime. These sound levels measured in several countries were found to be 5570dBA, a level above the recommended from the World Health Organization and in
the region of noise that could potentially induce added stress to the patients. In this
experiment the patients were listening to music through headphones from an MP3
player. The effect was twofold while music masked outside sounds and the total noise
("unwanted sound" according to World Health Organization) thus immediately
lowering the noise stress levels and succeeded in further lowering the overall stress of
the participants.
A major stressful environment is the university, where students need to cope with
being away from home or living alone for the first time, the pressure of academic
excellence and the fear of failure and the balance between lectures, assignments, part
time work and social life. Prolonged stress may be a great inhibitor in a student's life
having an impact to academic performance and might even lead to destructive
behavior or substance abuse (Ross, et al.1999). A recent study with college students
of California State University (E. Ferrer et al. 2014) was contacted during four years
were participants were asked to listen to songs from a list including various genres
and then report stress level before and after the experiment using a Likert scale. The
experiment was repeated with songs chosen from the instructor. For each year, the
mean results and the p-values confirmed an overall decrease in the stress levels of the
study population in both experiments, although individuals reported certain songs
having no or negative effect. Students also reported better results with their favorite
music than music chosen by the instructor. While the short term effects observed were
important, a longer study during a whole academic semester or year would be
beneficial.
On the field of occupational stress (i.e. stress at the working environment) the
literature is not as rich. A study by Cooke. M et al. (2006) on stress levels of
emergency room nurses music in combination with massage and aromatotherapy was

used over two 12 week periods and while the results showed a significant decrease in
occupational stress levels of the subjects, the variables were not evaluated separately
and there can't be a conclusive observation for music effects in this case. An
interesting case was with a group of computer company employees who were asked to
participate in a 3 week trial where they could listen to music at work during weeks
one and three but not during week two (Lesiuk 2010). The recorded music could be
either from their own collection or the author's list with genres ranging from classical,
pop to heavy metal, jazz and spiritual. Participants reported positive emotions,
decrease in stress and even in improvement in the quality of work between the music
and non-music weeks.
An interesting example of self administrated use of music in relation with stress is
examined by Toyoshima et al. (2011) who compared the effects of playing the piano
with other creative activities (calligraphy and clay molding) in a group of college
students. While cortisol levels and stress measured with the State-trait anxiety
inventory were decreased in all cases versus the control group, the piano playing
group reported a greater decrease in stress.
Finally, a review of 22 quantitative studies over 30 years (Pelletier C.L. 2004)
including experiments with occupational stress, college students, post or pre operative
stress, childbirth and dental procedures demonstrated a statistical significant decrease
in arousal due to stress with music therapy alone or with combination to other
relaxation techniques.

Music types
An important variable that should be determined in this research field is the type of
music can be used to combat stress and pain. Do all types of music work? Is music
with lyrics better than instrumental? Labbe. E. et al. (2007) studied college students
who were exposed to a number of music genres after a stressful test. The types of
music used were classical, heavy metal, "self selected relaxing music" also sitting in
silence was used as a fourth alternative. The results showed that listening to classical
and self selected music had a calming effect and the students experienced a reduction
in anxiety while those from the heavy metal group had an increase in stress levels
after exposure to music although the authors noted the participants were students and
the results "might not be appropriately generalized". Similar results were also
observed by Burns et al. (2012) with Serenata Notturna, KV239 by Wolfgang Mozart
as the classical condition and hard rock music (Alice in Chains) taking the place of
heavy metal in the experiment.
When investigating what kind of music is more suitable for use in reducing stress
and pain one should consider the tempo, rhythm and tonality. White (2000) suggested
the use of nonlyrical music with a predominance of string and as little brass and

percussion instruments as possible. Knight and Rickard (2001) considered "slow and
flowing" rhythm, 60-80 beats per minute. Knight & Rickard (2001) argue that the
patient's preference has to be taken into account and may be used regardless of tempo,
rhythm or style. Indeed, Mitchell, L and MacDonald, R.(2006) in an experiment on
pain tolerance using induced cold pressor pain showed that participants who listened
to their preferred music showed increase tolerance to pain than those that listened to
relaxing music or white noise. Research thus points to the fact that listening to the
favorite music may perhaps be more important than rhythm, genre or structure.

Conclusion and further work

Review of the literature agrees with the hypothesis that music and music therapy has
positive effects to stress management, stress levels and pain perception. It has many
advantages, including relatively low cost, universal use and effectiveness in all ages,
cultures, occupations and health issues, lacks any side effects and compares favorably
in that manner to pharmaceutical products and can be used both as a stand-alone or a
supplementary therapy. Music's effects have strong physiological roots and shouldn't
be viewed merely as a psychological phenomenon although due to the complexity of
the human body a number of theories exist and the exact physiological responses are
yet to be determined. Examining the type of music that should be utilized, research
agrees that preferred music demonstrated better results than assigned music.
Among the issues that need to be addressed for further work in the field are the long
term effects of music. Most studies are conducted in a short window of time and while
an improvement in pain perception and stress is reported many times, there seems to
be a lack of critical information on how long do the positive influences last and how
often should a person listen to music to maintain the positive outcomes on stress and
pain. Furthermore, while chronic illnesses are accounted for especially in hospice
environment, further research on the effect of music in chronic pain (pain after an
accident, arthritis etc) would be beneficial.
A review of several articles about pain and stress related to music has demonstrated
that a big part of the literature focuses on locations like hospitals, and medical offices
with patients and universities with students. While the above work is important some
focus of future research to the general population and other locations would be
beneficial. In addition, the effects of music listening to everyday life regardless of
location and situation is a field that hasn't been yet well documented.
Finally, occupational stress especially in jobs that are usually considered high-stress
like nurses, doctors, teachers, policemen or drivers can be managed through music
and is an area that hasn't yet be examined thoroughly by the literature and may be a
potentially interesting further work.

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