During the past six months since my post about beta blockers and performance anxiety, I’ve received several dozen communications from classical musician friends and CMT readers with questions and suggestions about additional approaches to managing stage fright. I’ve collected the more common ones together here, for your interest.
Q: I tried propranolol, but it made me feel a little ‘slow’ or depressed. Are there other alternatives that might work better for me?
A: There are a variety of beta blockers available. Propranolol and other non-selective β blockers often have more side-effects than metoprolol (Lopressor®) and atenolol (Tenormin®), which are selective for β1-adrenergic receptors. Lopressor and Tenormin reduce lung function (FEV1 and FVC) significantly less than non-selective beta blockers at equivalent β1-receptor blocking doses. And, although beta-blockade in anxiety has not been extensively studied, it does appear that it is the β1-selective activity that is responsible for the anti-anxiety effect—see the old paper by Cooper and coworkers [Cooper S, Kelly C, McGilloway S, Gilliland A. Beta2-adrenoreceptor antagonism in anxiety. Eur Neuropsychopharm 1990; 1:75-7.] for more information. You may want to visit your physician and discuss trying a low dose of one of the β1-selective beta blockers.
Q: Is there any reason that metoprolol (Lopressor®) would be better or worse than atenolol (Tenormin®) for managing stage fright?
A: There is no controlled study that has evaluated this. Both are β1-selective beta blockers. Atenolol has a higher potency on a per-milligram basis, so the amount of drug needed to produce the same level of β1-selective beta blockade is smaller than for metoprolol. And on a population basis, atenolol tends to have a shorter time to maximum blood concentration (shorter Tmax), so it may tend to have a more predictable timing with regard to effectiveness in minimizing performance anxiety. But these pharmacokinetic parameters show considerable variation from person to person for both drugs (for all drugs). So there is no way to predict in advance which might work best for an individual musician. Just try one for awhile and see. And, if it isn’t satisfactory or has objectionable side-effects, then consider trying the other for awhile and comparing.
Q: Are there alternatives to beta blockers? What other types of drugs have some effectiveness for managing performance anxiety?
A: At the time of this post, there are no new refereed journal articles addressing this directly. But, during the six months since I last posted on this topic, a number of performing musicians have indicated to me that they have tried low-dose prazosin (Minipres®) with good results. Prazosin has recently been studied in patients with post-traumatic stress disorder (PTSD), and there are a dozen articles that have been published characterizing the experience to-date. Larger doses of prazosin can cause a drop in blood pressure when standing up from a sitting or lying position. The 2 mg dose is unlikely to give this problem, unless you have low blood pressure for other reasons or are on other antihypertensive medications. Prazosin is an anti-hypertensive drug that’s been available for decades. Its effects and safety profile are well-known, and it is quite inexpensive.
Q: What about Zoloft®?
A: Probably not a good idea. I did receive a couple of comments about the use of Zoloft® (sertraline), which is a selective serotonin reuptake inhibitor (SSRI) antidepressant that is approved for use in PTSD and panic attacks in addition to depression. But SSRIs have to be taken daily on a chronic basis to work. Zoloft has a latency of 4 or 5 weeks to produce its effect, and its long (6 to 8 h) time to reach peak plasma concentrations and long (26 to 30 h) half-life make it unreasonable as a choice for occasional single-dose use prior to a performance. The objective of the performer who wishes to prevent or manage performance anxiety is to avoid taking medication chronically; the objective is to identify a medication that can be taken acutely, as a single dose immediately prior to a performance. And, ideally, a medication suitable for this purpose should be safe and non-addictive (should not have ‘tolerance’ or abuse potential), should not have undue systemic side-effects, should be inexpensive, and should be compatible with other medications the performer may need to take for other health conditions.
Q: I have a musician friend who was put on Campral® and unexpectedly experienced a reduction of pre-performance anxiety. What about that?
A: Campral® is used to treat alcoholism and other ‘craving’ disorders. There are no published studies regarding the use of acamprosate (Campral®) to manage stage fright. But the GABA and mtALD mechanism of action of Campral® offers a plausible but speculative basis for thinking that the drug could be helpful. And it causes virtually no impairment in memory or other cognitive measures. It takes between 3 and 8 hours to reach peak blood concentrations, though, so you’d have to take it at least 3 hours prior to performing. If you decide to try this, please post a comment here on CMT to let me know how things go.
Q: What about other vasodilator drugs?
A: There are a few journal articles regarding nitroglycerin or isosorbide dinitrate or other vasodilator/nitric oxide-donor drugs and their unexpected effect in reducing anxiety. The effects of nitric oxide (NO) are not mediated only through systemic vasodilation. Soluble guanylyl cyclase (sGC) is activated in many tissues including the brain. And selectivity is observed for sGC in the hippocampus. Hippocampal levels of phosphorylated ERK1/2, a postulated intermediary in the biochemistry of recall and formation of long-term memories, are increased. So nitric oxidergic compounds may actually achieve their efficacy in performance anxiety via direct effects on memory. If you're performing music from memory and your recall is enhanced, you have less cause to be anxious. In moderate doses, cardiac nitrate drugs can cause headache or other side-effects that would probably bother a performer—disadvantages outweighing whatever advantage they offer. But low-dose formulations—and especially transdermal or lingual aerosol ones—tend not to cause these side-effects and may be worth trying. How these help to ameliorate stage fright isn’t clear. And do keep in mind that your body develops a tolerance to nitrates over time if you use them frequently.
Q: Would I ever want to combine two or more of these? A beta-blocker plus prazosin, say? Or a beta-blocker plus a nitroglycerin patch?
A: There is no medical literature on this, with regard to stage fright per se. But these cardiovascular drugs are routinely used together in patients with hypertension and heart disease. It’s possible that using a combo could be helpful—either in terms of reducing the amount of one or both drugs that you need to achieve the effect that you’re aiming for, or in terms of the pharmacokinetics (onset and duration of action). Talk to your physician about it.
Q: What about baclofen?
A: The γ–amino butyric acid (GABA) mechanism of action for this muscle relaxant would make me worry about it causing objectionable cognitive side-effects. And there is some potential for dependency. I’d try to stick with one of the other alternative choices if I were you.
Q: I find that when I’m taking Singulair® I have distinctly less performance anxiety. Has anybody else reported that?
A: Two performers who have asthma wrote to me during the summer saying basically this same thing. The leukotriene receptor antagonist (LTRA) drugs—montelukast (Singulair®), zafirlukast (Accolate®), and pranlukast—are anti-asthmatic drugs that interfere with inflammatory cytokine proteins and other components of the inflammatory process. LTRA drugs can modulate nitric oxide (NO) production, which is dramatically increased in asthmatics. Possibly these drugs have unexpected vascular and anti-anxiety effects that’re mediated through nitric oxide and vasodilation. If so, the effects must be pretty subtle, because there’s no medical journal literature on it. Articles concerning the dramatic reduction in pulmonary production of NO, but no articles on anxiolytic effects or hypotension. And nothing about these effects in normal, healthy people who do not have asthma. Not sure whether you could persuade a physician to prescribe one of these for you “off-label” if you don’t have asthma.
Q: What criteria make a medication suitable or unsuitable for managing performance anxiety?
A: Besides the relative absence of systemic and neurological side-effects, I mentioned that you want a drug that has a rapid onset of action and does not have to be taken chronically. You want a drug that has a half-life that is longer than the duration of your performance, since you probably do not want to be repeating doses during the interval. (Nitroglycerin has a short half-life of only minutes, but the transdermal patch continues to deliver drug across the skin for the hours when the patch is applied. The Nitromist® aerosol spray may be used to get prompt blood levels while you’re waiting for the Nitrodur® patch to “kick in”.) You want a drug that has little or no tolerance or abuse potential. This is not only a good idea for your own health, but is also a factor that will determine how reluctant a physician will be to write a prescription for an “off-label” indication like performance anxiety. (If the drug is abusable, then it’s unlikely that an ethical physician will readily agree to prescribe it.) Finally, you want a drug that’s reasonably inexpensive. If you do not have one of the conditions for which a drug is approved, the prescription will be “off-label” and your insurance or health plan may not cover it, in which case you will be paying for the drug ‘out-of-pocket’.
Here is a spreadsheet with information collated from the Q&A above, plus some pharmacologic properties for each drug. CMT should not be considered as medical advice, and the remarks in these blog posts are not a substitute for professional medical advice, diagnosis, or treatment. Never delay or disregard seeking professional medical advice from your physician, pharmacist, or other qualified healthcare provider because of something you have read on CMT. You should always speak with your doctor before you start, stop, or change any prescribed part of your care plan or treatment. CMT understands that reading individual, real-life experiences may be a helpful health information resource but they are never a substitute for professional medical advice from a qualified healthcare provider. Hypnosis, biofeedback, and other non-pharmacologic alternatives may be useful.
It is not always obvious where the border should be defined between a mild symptom and a disorder that needs medical attention. In addition to forming alliances with patient groups, drug companies also attempt to maximize the detectable prevalence of conditions as part of the economic rationale for growing the market for the medications. Once you decide on a threshold [goal target outcome, for symptoms or a biomarker surrogate] ... and once you decide there's a drug that could achieve that in a population, they have a strong incentive to market to that whole population [whose untreated symptoms or biomarker levels are significantly different from that goal].”
— Joe Dumit, MIT (quoted by Wolinsky, 2005)
- Maisel E. Performance Anxiety: A Workbook for Actors, Singers, Dancers, and Anyone Who Performs in Public. Watson-Guptill, 2005.
- Goode M. Stage Fright in Music Performance and Its Relationship to the Unconscious. Trumpet Works, 2003.
- DSM. Managing Stage Fright & Performance Anxiety in Classical Musicians. CMT, 17-MAY-2007.
- Prof. Dianna Kenny at Univ of Sydney Conservatorium of Music, Australian Centre for Applied Research in Musical Performance.
- Osborne M, Kenny D. Development and validation of a music performance anxiety inventory for gifted adolescent musicians. J Anx Disord 2005; 19:725-51.
- Wolinsky H. Disease mongering and drug marketing. EMBO Rep 2005; 6: 612-4. [80KB pdf]
- MAPS.org MDMA Research Index
- Global Information Inc. Pipeline Insight: Anxiety Disorders. MAR-2003.
- Huffman J, Stern T. Neuropsychiatric consequences of cardiovasular medications. Dialogues Clin Neurosci 2007; 9:29-45.
- Taylor F, et al. Daytime prazosin reduces psychological distress to trauma specific cues in civilian trauma posttraumatic stress disorder. Biol Psych 2006; 59: 577-81.
- Manion S, Gamble E, Li H. Prazosin administered prior to inescapable stressor blocks subsequent exaggeration of acoustic startle response in rats. Pharmacol Biochem Behav 2007: 86:559-65.
- Strawn J, Geracioti T. Noradrenergic dysfunction and the psychopharmacology of posttraumatic stress disorder. Depress Anxiety 12-MAR-2007.
- Sade K, Kivity S. Nitric oxide in asthma. IMAJ 2002; 4:196-9 [1MB pdf]
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