jwilzewske: Managing Stage Fright & Performance Anxiety in Classical Musicians

Before beta blockers, I saw a lot of musicians using alcohol or benzodiazepines. I believe beta blockers are far more beneficial than deleterious, and I have no qualms about prescribing them.”

— Mitchell Kahn MD, Director, Miller Healthcare Institute for Performing Artists

Edgar Ende, El Espejo en El Espejo: Un Laberinto, 1947

DSM: A friend of mine, an experienced pianist accustomed to performing frequently in public, recently confided to me how much she’s still affected by “jitters” before a concert, despite the years that she has been playing and building her career. In fact, as her career has progressed and the concert dates have become more frequent, she notes that the pre-concert anxieties have been getting worse, not better. Her heart thumps loudly; she feels distracted, so much so that she worries about forgetting passages that she never in fact forgets; and her head feels as if it were burning up. Her hands shake, and the tension in her arms and wrists keeps her from performing with her normal sensitivity and nuance.

CMT: This is your friend who has a couple of recent CDs?

DSM: Yes. With the positive reviews that those have received has come more frequent coverage by critics in the press. And, at least in her mind, she imagines more people in her audiences arrive at the concerts expecting a particular kind of experience or level of performance or interpretation that her recordings or the reviews have conditioned them to expect. She feels she’s no longer the obscure academician playing her heart out. Admittedly, performances were never carefree. But now she feels the stakes are magnified each time she strides onto the stage. That’s what makes her “jitters” worse. Breathing exercises and yoga and other things she’s tried seem not to have been effective . . .

CMT: What do you think? Should she see a clinical psychologist or therapist about it? What about medications that are at all effective for stage fright or “performance jitters”—ones that would not majorly blunt her acuity or sedate or otherwise interfere with her performance practice? I know that beta blocker antihypertensive drugs are used by quite a few people. And half-dose escitalopram or half-dose diazepam are used by some.

DSM: Well, frankly, there are some psychologists who work with performing artists and claim to have approaches that are reasonably effective.

CMT: What about the meds, though? What’re the current statuses of those?

DSM: To me, that’d be somewhat a last recourse, something to try if other things fail. But, yes, there are several alternatives that enjoy a degree of effectiveness. All of them would be prescribed off-label, of course. None of them is specifically designed or approved for use in performance anxiety as such.

CMT: Yes, well, the transformation of “enhancements” into “treatments” is now a familiar part of medicine, of course, and it’s been accelerated by medicine’s move into the consumer marketplace. Carl Elliott’s essay in this week’s New England Journal of Medicine (17-MAY; 356: 2024-5) notes that physicians today prescribe drugs to lengthen attention spans, strengthen erections, and smooth out wrinkled brows, even when they are not entirely convinced that what they are treating is a medical need rather than merely a consumer desire. Many others write prescriptions for conditions that blur the boundary between pathology and ordinary human variability: synthetic growth hormone for short stature, SSRI and NERI antidepressants for social anxiety disorder, and hormone-replacement therapy for the effects of menopause (although the risks that militate against that one are now recently pretty clear-cut). The line between what consumers want and what patients need has become blurred beyond recognition. So why should chamber music be any different?

DSM: Many people feel uneasy about this, including me, without being able to say exacly why we feel uneasy. Michael Sandel’s fine new book, ‘The Case against Perfection’, aims to characterize that unease. Sandel is not so much bothered by the specific enhancements and abilities that consumers might choose (my own accomodating or preferring deafness and stapedial spasms rather than super-hearing, for example) or even the possibility that these procedures will be bought and sold in the marketplace. It’s the commodification of human experience itself. Sandel worries that more genetic choice will undermine our appreciation of the gifted character of human life—our sense that the way we are is not solely the product of our own doing. For Sandel, the effort to bring our physiologic or psychologic or genetic constitution under our voluntary control represents a kind of hubris. Standing face to face with a marvel of biology, one produced by eons of natural selection, we decide we can do better.

CMT: Many Americans see choice as a categorical good: the more we have, the better. I think other people in other countries have maybe a more balanced view. But as Sandel points out, choice is everywhere a mixed blessing. The more control we exercise over our identities, our capabilities, our deficiencies, our limitations—the greater our responsibility for the results. Weaknesses and minor afflictions that we could once blame on Nature or Fate, we’re now able to blame only on ourselves. The illusion that you can ‘master’ or ‘control’ things is an illusion—an illusion that can leap up and bite you. Look at all the failed plastic surgery walking around! So what about medications in pre-performance “jitters”?

DSM: Beta blockers, taken in small dosages, can quell anxiety without apparent side effects. The article in the New York Times by Blair Tindall several years ago was the first piece in the lay press I’d seen about that, despite the fact that it’s really common practice.

Lopressor® (metoprolol), 50 mg
Tenormin® (atenolol), 25 mg
Visken® (pindolol), 5 mg
Corgard® (nadolol), 40 mg
Blocadren® (timolol), 20 mg
Trandate® (labetalol), 100 mg
Inderal® (propranolol), 40 mg

One of these can be taken an hour or two before a concert. You don’t have to take them every day. In fact, you probably would prefer not to take them on a routine, daily basis. That way, the drug’s effectiveness for mitigating the pre-concert anxiety is preserved. Your body isn’t accustomed to having the drug on board all the time. And these doses are small enough that the usual beta-blocker side-effects (drowsiness or fatigue; cold hands and feet; weakness or dizziness; dry mouth, eyes, and skin; trouble breathing, or shortness of breath; libido changes) would almost certainly not occur, especially in these reduced single-dose pre-concert-only amounts.

A beta-1-selective adrenergic receptor blocking agent like metoprolol or atenolol is probably best. In vitro and in vivo studies have shown that it has a preferential effect on beta-1 adrenoreceptors, chiefly located in cardiac muscle. This preferential effect is not absolute, however, and at higher doses such as are used in treating severe high blood pressure, the beta-1-selected drugs can also block beta-2 adrenoreceptors, chiefly the beta-2 receptors on the cells located in the bronchial and vascular musculature. Clinical pharmacology studies have confirmed the beta-blocking activity of metoprolol and other beta-1-selective adrenergic blockers, as shown by (1) reduction in heart rate and cardiac output at rest and under stress, (2) reduction of systolic blood pressure upon exercise, (3) inhibition of stress-induced or isoproterenol-induced tachycardia, and (4) reduction of reflex orthostatic tachycardia.

Relative beta-1 selectivity has been confirmed by the following: (1) In normal subjects, metoprolol’s unable to reverse the beta-2-mediated vasodilating effects of epinephrine (adrenaline). This contrasts with the effect of nonselective (beta-1 plus beta-2) beta blockers like propranolol, which completely reverse the vasodilating effects of epinephrine. (2) In asthmatic patients, metoprolol and other beta-1-selective blockers don’t reduce pulmonary function like FEV1 and FVC as much as a nonselective beta blocker (such as propranolol or timolol or labetolol or nadolol or pindolol) would do at an equivalent beta-1-receptor-blocking dose. So if you’re a singer or a wind instrument player you want a beta-1-selective for sure, but even if you’re a keyboardist or a string or percussion player you probably want a beta-1 selective drug too.

Musicians quietly began to do beta blockers after their application to stage fright was first published in The Lancet, the British medical journal, in 1977. By 1987, a survey conducted by the International Conference of Symphony Orchestra Musicians, which represents the 51 largest orchestras in the U.S., found that 27 percent of its musicians had used the drugs. Psychiatrists at centers that treat professional musicians now estimate that the number’s much higher today. Robert Barris, bassoonist and a co-Chairman of the Music Performance faculty at Northwestern University, encourages students to address the root cause of their anxiety instead of relying on medications, though. He tends to recommend yoga and exercise. The only issue is that those take a long time to be effective and in some cases they aren’t effective. Many people don’t have the patience for that; they just prefer to go with the sure-fire, pharmaceutical solution, especially since that usually just involves single low-dose use right before the performance.

The information on this page is not intended as medical advice and is not meant to be a substitute for individual medical judgment by a physician or other medical healthcare professional. The aim is to provide information and help in suggesting considerations for preventive care. Beta blockers should be used only after a medical examination and under the supervision of a doctor, of course. This is because people with asthma or heart disease could develop problems like shortness of breath or heart failure or a slowing of the heart rate. Remember, always consult a licensed healthcare provider for individualized advice on your health decisions.

If you have to take a drug to do your job, then go get another job.”

— Sara Sant'Ambrogio, Cellist and founding member, Eroica Trio.

jwilzewske

Thursday, May 17, 2007

Managing Stage Fright & Performance Anxiety in Classical Musicians

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