Beta-Blocker Meds and Spasms in Classical Musicians

During the past six months, I’ve received a dozen communications from classical musician friends and CMT readers with questions and suggestions about beta blocker medications and muscle spasms. I respond to the two common ones together here, for your interest.

Q: I tried Corgard® 80 mg for stage fright and almost right away began having wheezing and asthma. This has happened three times. Is it just my imagination or is it because of the Corgard®?
A: There are a variety of beta blockers available. Propranolol (Inderal®) and nadolol (Corgard®) and other non-selective β blockers often have more side-effects than metoprolol (Lopressor®) and atenolol (Tenormin®), which are selective for β1-adrenergic receptors. Corgard® is indicated for the management of patients with angina pectoris (chest pain due to coronary artery disease), in doses from 40 mg to 240 mg per day. Corgard® is also used in the management of hypertension, in doses from 40 mg up to 320 mg per day. It is used either alone or in combination with other blood pressure medicines, especially thiazide-type diuretics. Peak blood concentrations of nadolol usually occur within four hours after oral administration, although the propensity for asthma-like bronchospasm is not limited to the period around the peak concentration. The drug has a half-life from 20 to 24 hours, except in people with significantly decreased kidney function, in whom the half-life is considerably longer. Propranolol and nadolol both tend to have more bronchospasm asthma-type side-effects than selective beta blockers at equivalent β1-receptor blocking doses. You may want to visit your physician and discuss trying a low dose of one of the β1-selective beta blockers for your performance anxiety, instead of the Corgard®.

Q: My dose of Corgard® was recently increased, to bring my blood pressure down. Over the past month I notice a kind of spasticity when I am playing [piano]. It’s like there’s a sort of ‘ratcheting’ that the muscles in my arms and shoulders do. It takes more effort to begin a motion and then, once my arm is moving, it tends to jerk or ‘overshoot’ in an odd way. It’s about the same on the left and the right side. It’s worse when I first begin to play and also when I’ve been playing for a long time and I am getting fatigued. Is this something caused by the Corgard?
A: Propranolol (Inderal®) and nadolol (Corgard®) and other non-selective β blockers often have more skeletal muscle side-effects than metoprolol (Lopressor®) and atenolol (Tenormin®), which are selective for β1-adrenergic receptors. Since muscle spasms or other muscular side-effects don’t interfere with ordinary activities of daily living, there is not much in the medical literature about them. People tend not to mention them to their doctors very often and, because the effects are not severe or limiting ordinary ‘coarse-motor’ muscular activity, academic physicians and researchers tend not to write scholarly journal articles about these side-effects. Pharmaceutical companies have not sponsored research in these areas. But that doesn’t mean that the effects don’t exist. And the effects can be limiting or ‘severe’ for professional musicians, whose performance critically depends on fine motor control. I’ve mostly heard from pianists and string players concerning them. I have not heard from any woodwind or brass player who has complained of muscle spasms on a non-selective beta blocker like Corgard®, possibly because the scale or dimensions on which performance depends for those instruments is smaller than for piano, strings, or other instruments. There is actually some old literature that suggests that a non-selective beta blocker taken by itself may help reduce or suppress a type of muscle hyper-reactivity/spasticity called ‘clonus’, but that effect is dose-dependent. Other older journal articles on the neurophysiology and pharmacology of non-selective beta-blockers show that twitch or spasm is augmented or enabled by blocking beta2 receptors. Recent work has looked in detail at beta2 and beta3 receptors in skeletal muscle, with genomic and proteomic methods that weren’t available thirty to forty years ago when the early studies were done. And recent biomechanics modeling has quantitatively evaluated the respective contributions of (and differential strains between) different parts of muscle bellies in contraction, revealing how imbalances in contraction can originate [in a manner that plausibly could be affected by medications, as well as other factors]. So, yes, a ratchet-like, hyper-reflexive, twitchy muscle action is plausibly related to the non-selective beta blocker. Incidentally, if a beta blocker is combined with a thiazide or other potassium-wasting diuretic for blood pressure control, then an abnormal potassium level may contribute to the muscle spasms you are experiencing. You may want to visit your physician and discuss adjusting your medication regimen, or trying an appropriate dose of one of the beta1-selective beta blockers instead of the non-selective Corgard®.

Note: 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.

• Blemker S, Pinsky P, Delp S. A 3-D model of muscle reveals the causes of nonuniform strains in the biceps brachii. J Biomech 2005; 38: 657-65. [1MB pdf]
  
• Bohmer K, Raper C. Sympathomimetic-induced effects in soleus muscle of the guinea pig. Arch Int Pharmacodynam Ther 1976; 221: 60-5.
  
• Collet F Feve B, Frisdal E, Pavoine C, Pecker F, Atlan G. Pharmacological and molecular characterisation of beta-adrenoceptors in adult rat diaphragm muscle. Respir Physiol 1998; 112: 1-12.
  
• DSM. High Anxiety. CMT blog, 12-NOV-2007.
  
• Endo M, Matsumoto N, eds. Beta Blockers: New Research. Nova Science, 2008.
  
• Holmberg E, Waldeck B. Analysis of the beta-receptor mediated effect on fast-contracting skeletal muscle in vitro. Naun Schmied Arch Pharmacol. 1977; 301: 109-13.
  
• Holmberg E, Jeppsson A, Lamm C, Waldeck B. The adrenoceptor blocking properties of the new beta 2-selective antagonist, IPS 339 on tracheal smooth muscle and on slow contracting skeletal muscle. Acta Pharmacol Toxicol 1980; 46: 150-5.
  
• Mai J, Pedersen E. Clonus depression by propranolol. Acta Neurol Scand 1976; 53: 395-8.
  
• Sillence M, Hooper J, Zhou G, Liu Q, Munn K. Characterization of porcine beta1- and beta2-adrenergic receptors in heart, skeletal muscle, and adipose tissue, and the identification of an atypical beta-adrenergic binding site. J Animal Sci 2005; 83: 2339-48.
  
• Waldeck B. Analysis of the beta-receptor mediated effect on slow-contracting skeletal muscle in vitro. J Pharm Pharmacol 1977; 29: 550-4.

What’s Up with Stage Fright and Chamber Music?

W  hat about nutraceuticals or dietary approaches for stage fright? Aren’t there any over-the-counter supplements that work? What about amino acids? What about melatonin? I’m in a managed-care plan and I never get to see the same doctor twice. And the docs won’t ever spend more than 6 minutes talking to me, at best. The clinic schedule is so busy, they just go jumping from exam room to exam room. And the doctors’ decisions are reviewed and second-guessed by all these bean-counter administrators and compliance people. There’s no way I can go in there and ask for a prescription for a beta blocker or one of the other meds for performance anxiety you’ve written about in these blogs. Bells and whistles and alarms would go off. For all I know, the managed care plan might even tell my employer about it. On top of which the doc probably wouldn’t write the prescription anyway. I don’t have high blood pressure or any other condition beta blockers are normally used for. Makes me mad. What options do I have?”
  — Anonymous.

There was never any intention to provide a forum here in CMT for frequent discussion and critiquing of stage fright and modalities for managing performance anxiety. But, surprisingly, the posts about stage fright are among the most heavily “hit” and searched, of the 150-odd posts currently on CMT blog. And the numerous emails and comments clearly show a latent unmet need out there.

I’m not sure why this topic is ‘striking such a chord’ for CMT readers. Probably it has something to do with the fact that chamber music orchestration and small ensemble performance are so ‘open’—the individual musicians’ exposure and risk are in general greater than they are when performing in larger orchestral or choral groups; the performance venues for chamber music are specifically ones whose acoustics accentuates the intimacy and exposure; and there’s absolutely nowhere to hide, no ‘room’ for error. Every note, every nuance, every mistake will be heard. And chamber music audiences are highly attentive and critical. These features make for an ‘unforgiving’ environment—less forgiving, anyhow, than other live performance genres and venues and audiences. In fact, I suppose that this indigenous ‘high-stakes intimacy’ is part of chamber music’s thrill and appeal, for performers and composers and listeners alike.

While my own preference is to rely on deep-breathing and other non-pharmaceutical practices, there are many CMT readers who’ve sent me emails about their experiences with beta-blockers and other of the approaches that’ve been covered in the previous posts. And, recently there’ve been a number of inquiries about whether the amino acid, 5-hydroxytryptophan (5-HTP), is useful for managing or preventing stage fright. This post describes my own informal trial of 5-HTP over the past 6 months.

I  originally tried 5-HTP, not because of performance anxiety but because I was having trouble staying asleep at night, due to situational stress at work. I didn’t want to use any strong prescription sleeping medications, but I’d heard that 5-HTP may help with sleeping. Then I came across the Turner and Schruers and Miller journal articles and decided to explore what 5-HTP’s effects might be on my music.

Initially, I tried the 100 mg immediate-release tablets, but the dose was too low (for me)—or possibly the immediate-release formulation allows too much of the 5-HTP to be destroyed by the acid in the stomach, and therefore I wasn’t actually getting a full 100 milligrams-worth. The rapid dissolution immediate-release also gave me some bowel upset 6 or more hours after taking the tablet. But the 200 mg extended-release formulation works well and has no G.I. side-effects for me.

The 200 mg extended-release tablets also offer a relative advantage in terms of gradual, gentler onset of action. The 5-HTP is predominantly absorbed in the small intestine, so you want the tablet to pass through the stomach relatively quickly and move on beyond, into the duodenum and jejunum. Take the tablets on an empty stomach. I take one tablet 2h prior to performance with 60 mL (2 ounces) of fruit juice or water. Then I take a second tablet 1h prior to performance, again with a small amount of juice.

The most noticeable thing for me is that my inner dialogue with myself quiets down. The aspect of pre-performance jitters that manifests itself with unspoken chatter in my mind: the internal chatter just subsides in a nice Zen-like way. My ‘edge’ is not blunted at all, but I feel more serene. Subtle, useful effect.

Very busy weeks have led me to try 5-HTP on several consecutive days. Then, the next day when I don’t take any 5-HTP, I feel a little ‘low’. There’s a bit of a ‘crash’. I’m not lethargic, not mentally dulled or distracted, not sleepy, not overtly clinically depressed. Just mildly ‘down’. (My normal delight in small good things that happen each day, where’s that? My inclination to go visit with friends, where’s that gone?) I’m back to my normal, chipper self by Day-2 or Day-3.

The experience with the ‘crash’ following multi-day use of 5-HTP makes me want to tell you that, despite the fact that 5-HTP is “just an amino acid” or “just an OTC food supplement”, it nonetheless does have medication-like properties in these doses and should be taken with a level of care and caution that would ordinarily accompany our use of any medication. Dietary supplementation with serotonin precursors (5-HTP, tryptophan, etc.) in doses sufficiently high to be effective in changing mood or performance anxiety or your emotional response to stress———is bound to change the equilibrium of the biochemical pathways and endocrine feedback loops that control serotonin metabolism—in your brain and in other organ systems. Gee—you wouldn’t expect going on and off a clinically-effective dose of SSRI to have zero side-effects, so why would you or I expect that going on and off a clinically-effective dose of 5-HTP would have zero side-effects?

In summary, 5-HTP seems to have significant efficacy for panic attacks and stage fright anxiety, as reported in recent research journal articles. Since I have only mild jitters and don’t experience severe performance anxiety myself, I can’t say whether 5-HTP is likely to work for you, those of you who have severe symptoms. And I can’t say whether its effectiveness is ‘durable’—don’t know whether significant ‘tolerance’ to 5-HTP’s effects develops if you use it continuously or for long periods; don’t know whether dose-escalation is needed to sustain efficacy with chronic use.

What I can say from my own first-hand experience is that acute, occasional 5-HTP use does seem valuable and is worth a try. It’s readily available without any prescription and it’s relatively cheap. It has only mild, transient side-effects with acute, occasional use in doses up to 400 mg. And, in my experience, its [low-dose, extended-release formulation— ] effects don’t adversely affect vision, hearing, touch, blood pressure, breathing, muscle coordination, memory, or other aspects related to music performance.

There’s no reason why 5-HTP use couldn’t be combined with one of the other stage fright prevention/treatment modalities (a beta blocker; or a vasodilator like prazosin; or an anticholinergic like biperiden or trihexyphenidyl; or an anticonvulsant like levetiracetam; or deep-breathing or biofeedback training or meditation). The mechanisms-of-action for those modalities [probably] don’t involve serotonin pathways.


The effects of the different modalities might be additive when used together—enabling you to achieve the effect that’s adequate for you at lower doses of each than would be required to achieve the same effect with either med by itself. If you’re now using 40 mg of propranolol, you might, for example, be able to do as well with 20 mg of propranolol plus 200 mg of the 5-HTP. Or maybe even 10 mg of propranolol and only 100 mg or 50 mg of the 5-HTP.

Similarly, it’s possible that using 5-HTP with deep-breathing or biofeedback or yoga or meditation may enable you to achieve the same efficacy at lower doses of the 5-HTP and lower intensities of the biofeedback exercises than would be needed if you were using one or the other of them alone.

V ajrayoginī carries a hooked knife (kartari; triguk) known as the ‘Hook of Mercy,’ the weapon of non-thought that cuts the deceptions of self-cherishing. Non-thought (togme) is the most basic expression of Vajrayoginī, for her mind is completely free from subconscious chatter and from habitual patterns that give rise to obsessive thoughts. Non-thought is a purified form of ignorance, traditionally symbolized in Buddhism by a pig. In this sādhana, the dākinī is secretly known as Vajravārāhī, and her ignorance is transformed into freedom, the wisdom of limitless space.”
  —  Judith Simmer-Brown, p. 142.

Conversely, I think combining 5-HTP with an SSRI or with a benzodiazepine or with Risperdal or Buspar would be a distinctly bad or unsafe idea. Possible risk of ‘serotonin syndrome’ or other adverse effects.

You should not take 5-HTP if you have any of the following:

• MAO inhibitor antidepressant use within the past 2 weeks;
  
• tricyclic antidepressant use within the past 2 weeks;
  
• SSRI antidepressant use within the past 2 weeks;
  
• triptan antimigraine use within the past 2 weeks;
  
• history of angina, myocardial ischemia, heart attack, cardiac arrhythmia;
  
• pregnant;
  
• breast-feeding;
  
• carcinoid tumor .

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. The medications listed should be used only after a medical examination and under the supervision of a doctor. Always consult a licensed healthcare provider for individualized advice on your health decisions.


Click on the screenshot below to download the API (Acute Panic Inventory) questionnaire, to calculate the severity of your symptoms. You may like to keep a log of how your symptoms change over time, when you perform in different settings and when you try different approaches to manage your stage fright symptoms. The performance anxiety you experience may not properly be ‘panic attacks’ per se, but the API is probably the instrument that’s been most frequently used in longitudinal research on these sorts of symptoms. If you measure your experiences with the API and look for trends and correlations with what you’re doing to manage the symptoms, that will help you to assess what’s working and what’s not. Let me know how it goes, and I’ll continue to share things from time to time here on CMT.

• Aaronson H. Buddhist Practice on Western Ground: Reconciling Eastern Ideals and Western Psychology. Shambhala, 2004.
  
• Coleman J. The Quiet Mind. Pariyatti, 2000.
  
• Davich V. 8 Minute Meditation: Quiet Your Mind. Change Your Life. Perigree, 2004.
  
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• Kundtz D. Quiet Mind: One-Minute Retreats from a Busy World. Redwheel, 2003.
  
• Livingstone P. Let's Not Call It Meditation: Practical Guidance for People Who Think They Can't Sit Still and Quiet the Mind. HWA, 2006.
  
• Michie D. Buddhism for Busy People: Finding Happiness in an Uncertain World. Allen & Unwin, 2005.
  
• Shaw S. Buddhist Meditation: An Anthology of Texts. Routledge, 2006.
  
• Simmer-Brown J. Dakini's Warm Breath: The Feminine Principle in Tibetan Buddhism. Shambhala, 2002.
  
• Watson G. The Resonance of Emptiness: A Buddhist Inspiration. Routledge, 2002.
  
• Wolter D, ed. Losing the Clouds, Gaining the Sky: Buddhism and the Natural Mind. Wisdom, 2007.
  
• U.S. FDA notice on tryptophan issues
  
• U.S. NIH study of EMS
  
• GNC 5-HTP 200 mg ER
  
• GNC L-tryptophan 500 mg
  
• AN 5-HTP 100 mg
  
• VB 5-HTP 100 mg
  
• Das Y, Bagchi M, Bagchi D, Preuss H. Safety of 5-hydroxy-L-tryptophan. Toxicol Lett. 2004;150:111-22.
  
• Klarskov K, Johnson K, Benson L, Gleich G, Naylor S. Eosinophilia-myalgia syndrome case-associated contaminants in commercially available 5-hydroxytryptophan. Adv Exp Med Biol. 1999;467:461-8.
• Miller H, Deakin J, Anderson I. Effect of acute tryptophan depletion on CO2-induced anxiety in patients with panic disorder and normal volunteers. Br J Psych 2000; 176:182-8. [400KB pdf]
  
• Schruers K, van Diest R, Overbeek T, Griez E. Acute L-5-hydroxytryptophan administration inhibits carbon dioxide-induced panic in panic disorder patients. Psych Res 2002; 113:237-43. [200KB pdf]
  
• Turner E, Loftis J, Blackwell A. Serotonin a la carte: supplementation with the serotonin precursor 5-hydroxytryptophan. Pharmacol Ther. 2006;109:325-38. [1MB pdf]
  
• StressEraser.com
  
• RESPeRATE.com
  
• RESPeRATE device at Amazon.com
  
• DSM. Stage Fright: More Treatment Options. CMT blog, 04-JAN-2008.
  
• DSM. High Anxiety: Prazosin and Other Alternatives. CMT blog, 12-NOV-2007.
  
• DSM. Managing Stage Fright & Performance Anxiety in Classical Musicians. CMT blog, 17-MAY-2007.

High Anxiety: Prazosin and Other Alternatives

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.
  
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• Global Information Inc. Pipeline Insight: Anxiety Disorders. MAR-2003.
  
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• 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]

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

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.

• Miller Healthcare Institute for Performing Artists, 355 West 52nd St, NY, NY 10019, 646-778-5550.
  
• Tindall B. Mixed Reviews for a Stage-Fright Remedy. Intl Herald Tribune, 21-OCT-2004.
  
• Tindall B. Better Playing Through Chemistry. New York Times, 17-OCT-2004.
  
• Benniger M, Murry T, eds. The Performer's Voice. Plural, 2006.
  
• Chaffin R, Imreh G, Crawford M. Practicing Perfection: Memory and Piano Performance. LEA, 2002.
  
• Elliott C. Better Than Well: American Medicine Meets the American Dream. Norton, 2003.
  
• James I, et al. Lancet 1977 05-NOV;2(8045):952-4.
  
• Sandel M. The Case against Perfection: Ethics in the Age of Genetic Engineering. Belknap, 2007.
  
• Tubiana R, Amadio P, eds. Medical Problems of the Instrumentalist Musician. Informa, 2000.
  
• CMT, Black-Key Biomechanics (Performing Arts Clinics list) 30-OCT-2006.