jwilzewske: stress

Showing posts with label stress. Show all posts

Thursday, May 22, 2008

Medical Performanceworthiness: Concertizing While Fatigued and Sleep-Deprived

O ur ensemble’s touring schedule this year is just brutal. The airline flights and weather-related delays are the worst part of it. The de rigeur dinners with presenters and their sponsors exact an additional toll. Our sleeping quality sucks, and it seems like our reaction-times in critical passages in performances also are ‘off’. We are perpetually fatigued. Seriously, I think it must be very much like ‘combat fatigue’, this perpetual sleep-deprivation, fatigue, high-risk performance situations, and confinement. Brutal! I’m not sure there’s anything that can be done about this—it seems inherent in the nature of a busy performing schedule. Of course we feel lucky, in a perverse way, to have this ‘problem’. But, artistically, it [the fatigue-related impairment of aesthetic values] makes me feel guilty and dissatisfied. Maybe the performance schedules of one or two hundred years ago had more healthy down-time, because travel from city to city naturally took longer. Maybe my envy, my nostalgia, is for a time that never ever was like that. The physical demands and continuous stress are so much more than [Conservatory training] ever prepared us for. It’d be nice to have some way to assess how ‘off’ you are, before going on-stage—or, better, the day before your next performance… time enough to maybe do something about the fatigue. Is there any way to objectively figure out how bad your ‘deficit’ is, to know how much rest you might need in order to get half-way back to ‘normal’?”
— Anonymous.

The comment above is reminiscent of the issues in a growing body of research in aviation, on ‘medical flightworthiness’—quantitative assessment of pilots’ cognitive and physiologic readiness to fly and to perform with adequate safety and precision when flying. There are a number of recent books and other resources that provide new insight into the effect of sleep-deprivation and mental and physical fatigue on cognition, emotion, and on-task performance. But relatively little research has been conducted/published regarding the impacts of fatigue on professional musicians. However, aviation and overland transport industries have commissioned scientific psychophysiology studies of fatigue-performance relationships for many decades, and, not surprisingly, there is a wealth of science on this that has been generated by the military in various countries. Most of the findings from those contexts are likely to be generalizable and applicable to the performing arts, including classical music.

J ames Miller’s human factors / ergonomics consultancy has a number of webpages and services that are relevant to the topic of this CMT post. And the Walter Reed Army Institute of Research, Psychiatry & Neuroscience Division (WRAIR-PN) has a number of tools for measuring fatigue, including a Palm-based software application that may be helpful for doing serial, self-administered measurements to inform ‘prevention’ or ‘planning’ interventions of the sort that the CMT reader’s comment/question has in mind (see links and screenshots below).

Most of the ergonomics and psychophysiology fatigue-performance research journal literature addresses changes in ‘error rate’ on-task, as a function of fatigue. In addition to error rate, performance is also measured in terms of the time taken to make decisions and check reference screens (‘decision-time’ and ‘check-time’). Subjective measures are also made of workload and environmental resources (personal control and support), of levels of anxiety and fatigue before the task, and of cognitive effort expended during the task. Measurements like these could be made on performing musicians under various conditions of stress and fatigue but, so far as I can tell, no such research has been published to-date. We have to take the results from the existing research literature and extrapolate to what it probably means for musicians.

Heart rate increases with increasing fatigue—not a good thing. Long eye-closure rate (LCR), blink amplitude (BA), eye movement ‘saccade velocity’, saccade rate, and peak saccade velocity all tend to increase (see Morris & Miller 1996, link below). Your response speed slows, despite the increase in sympathetic and parasympathetic nervous system activation. The number of ‘lapses’ in attention per minute increases (see Lamond et al. 2008, link below). You experience more severe and earlier exhaustion of coordination/interaction resolution abilities (see Persson et al 2007). In other words, all of your subjective impressions of what’s happening to your performance are true, or at least are very likely to be true (if findings from aviation and other high cognitive-intensity fields generalize to music)!

Studies by Strang and Berg at Miami University of Ohio show that fatigue has no effect on postural stability during the ‘focal’ movement, and yet caused earlier ‘anticipatory postural adjustments’ (APA) onsets in various muscle groups. In spite of ‘hyper-reactive’ early APA activations, the APA electromyograms of the postural control muscles stay pretty much the same. The findings suggest that fatigue-induced early APA onset is compensatory—it may enhance postural stability by permitting a longer duration APA which in turn counteracts the fatigue-related decreases in the force-producing capability of muscles that contribute to postural stability.

What else? Fatigue causes a decrement in vigilance, not just the ‘penalty’ in terms of slower reaction times (RTs) appearing after a few tens of minutes’ performance, depending on the intensity of the cognitive demands during those minutes. Additionally, fatigue interferes with learning/memorizing new sequences, consolidating memory of sequences already learned, and reinforcing your memory of, or the timing and precision of recall for, sequences that your brain has previously consolidated and stored. In other words, fatigue not only impairs your performance of what you already know; it impairs your learning and rehearsal of new things that you haven’t yet perfected. (This is part of the ‘guilt’ the CMT reader was implying in the comment above: a heavy touring schedule taxes your artistic growth, and this seems intuitively, morally ‘wrong’ to many musicians.)

Walker et al. (2003) suggest that when consolidated memories are retrieved [from memory, during performance], they again are labile and susceptible to interference, and require a period of reconsolidation in order to be preserved intact. Recently consolidated memories also benefit from rest intervals (Hotermans et al., 2006) to maintain their integrity as memories. Scary how performance while fatigued, by preventing such reconsolidation, may actually erode the integrity of the performance-related memories that you’ve invested so much effort to create!

If you’re really serious about undertaking the quantitative assessment of how far gone you are and how much rest you need, you can measure your own condition in the same way that the military does—with PDA-PVT (‘personal digital assistant psychomotor vigilance testing’), developed for Palm PDAs by David Thorne and coworkers at Walter Reed Army Institute of Research in Washington, DC.

Corware PalmPVT® stats: Pilot=Vln1, Copilot=Vln2, Gunner=Vla, Navigator=Vlc

Make yourself a spreadsheet or log, and record your measurements daily, just as you would do for your exercise regimen or weight management routine. Keep track of your hours of sleep/napping and other factors that you think are significant for your performance—and correlate these with your PDA-PVT measurements. Experiment with ‘recovery’ maneuvers (e.g., X extra hours of sleep, to recover from Y hours of sleep deficit) over a period of several months, and figure out your own personal program for mitigating the fatigue-related toll of your tour schedule.

Here are some gleanings from James Miller’s website that you may find useful:

Fatigue Countermeasures that Clearly Work

Adequate sleep;
Caffeine in moderate doses;
Napping;
Anchor Sleep (regular sleep period of at least 4h duration, obtained at the same time each night);
Performance Timing / Scheduling changes to provide ‘breaks’;
Good sleeping environment.

Fatigue Countermeasures that Require Supervision by a Physician

Alertness Aids;
Sleep meds;
Bright light;
Melatonin.

Fatigue Countermeasures that Do Not Work, or Cause Health Problems

Nicotine;
Ventilation or Air Conditioning changes;
Temperature adjustments;
Exercise (Do exercise for other health reasons, but not with any hope that it will help relieve the fatigue-related effects on your reaction-times or performance);
Diet and nutritional supplements;
White-Noise or other Ambient Sound maneuvers;
Odor/Fragrance aromatherapy.

Unfortunately, the fatigue aspect of occupational health in professional musicians is under-studied. I hope the links below are helpful. I’d be delighted to hear from you—one way or the other, good or bad—if you try the PDA-PVT software or other approaches. Thanks for the comments and questions!

Friday, February 1, 2008

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.

Tryptophan – Serotonin biochemical 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.

RESPeRATE breathing biofeedback training device

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.

StressEraser breathing biofeedback training device

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.