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BETA BLOCKERS AND PERFORMANCE ANXIETY IN MUSICIANS
A Report by the beta blocker study committee of FLUTE:
Karla Harby, freelance writer and amateur flutist
Kathrin Kucharski, clinical pharmacist and amateur flutist
Sarah Tuck (committee chair), professional flutist
Julia Vasquez, professional flutist
Beta blockers have been called "the musicians underground drug." Often musicians form their opinions, and may risk their health, based on locker-room-type information.
Performance anxiety can be a deeply personal subject for musicians, and many are reluctant to discuss all the possible remedies. It is our intention to bring this subject into the open, and to provide accurate information to inform personal opinions and decisions.
- 1. What are beta blockers (such as Inderal)?
Beta blockers block the receptors for the physical effects of a person's natural fight or flight response. They are not sedatives, and they can't help anxiety of a purely psychological nature.
Beta receptors are found in a number of places in the body: heart, lung, arteries, brain and uterus, to name a few. Like a key in a lock, beta blockers chemically fit into beta receptors and prevent norepinephrine from binding to the receptors that cause the symptoms of the fight-or-flight response.
The degree of these effects depends on the dose and the individual's sensitivity to the medication. Peak effect occurs in one to one and a half hours. Ideally, this could allow a performer to play at his or her best, without the distraction or interference of excessive fight or flight symptoms.
Blocking beta receptors can cause decreased heart rate; decreased force of heart contractions; bronchoconstriction (can cause asthma attacks in people with asthma); uterine contractions; decreased blood pressure; relief of migraines; and decreased tremor.
The beta receptors found in the different areas of the body are not all the same, thus different beta blockers may affect these areas differently. For instance, metoprolol (Lopressor) and atenolol (Tenormin) are beta-1 selective, which means they block only beta-1 receptors found primarily in the heart, but not the beta-2 receptors found in the lung and uterus. Thus, they can decrease blood pressure, heart rate and force of cardiac contraction, but are less likely to cause bronchoconstriction and uterine contractions. This selectivity is not absolute and depends on the dose.
Some beta blockers enter the brain better than others. Propranolol (Inderal) crosses the blood-brain barrier particularly well. This may be why propranolol causes more central nervous system side effects, such as hallucinations, nightmares, and depression, than the beta blockers that do not cross into the brain as easily.
Interestingly, the ability of beta blockers to help anxiety seems related only to their blockade of beta receptors outside of the brain. Beta blockers will not help the emotional symptoms of stage fright (for example, sleep problems or negative inner voices).
Everyone's body responds differently to beta blockers. For this reason it is important that each person experiment, under medical supervision, to find the ideal dosage for a performance situation. Similarly, it is important to take the beta blocker a few times and under different circumstances before a major performance to be sure the individual has no adverse reactions.
- 2. Do I need to see a doctor before taking them?
Everyone, without exception, must obtain their beta blockers from a physician. It is a violation of federal law in the United States, and many other countries, to give prescription medications to someone other than the person for whom they were prescribed.
Beta blockers are prescription medications for good reason. There are several conditions, such as slow heart rate, bronchial asthma, and heart failure, which can cause serious medical problems, even death, when taking this medication.
In addition, you should know that some psychiatrists and psychologists feel that beta blockers ought only to be used in the context of psychological intervention, and only as a temporary measure.
- 3. What kinds of problems are beta blockers good for?
One reference lists 29 different uses, including high blood pressure, angina, irregular heart rhythms, migraines, prevention of a second heart attack, tremors, alcohol withdrawal, anxiety and glaucoma.
In the United States, a physician can prescribe medications for uses not approved by the Food and Drug Administration, so long as there is scientific literature to support the use. Usually the pharmaceutical company involved will only research and develop a few uses to submit to the FDA to get the medication approved for marketing.
Once the medication wins FDA approval, the pharmaceutical company is only allowed to advertise it for FDA-approved uses. Over time, however, researchers and physicians gain experience using the medication for uses not approved by the FDA.
Beta blockers are not FDA approved for use in anxiety or stage fright, but these medications can be prescribed for this purpose because there is scientific literature to support this use.
- 4. Are beta blockers safe?
Only your physician can tell you whether beta blockers are safe for you.
Beta blockers can significantly worsen some medical conditions. As a general rule, beta blockers should not be used in asthmatic people. Beta blockers can worsen congestive heart failure, Raynaud's syndrome, and diabetes.
Musicians who take beta blockers often do so in small doses and only on special occasions, so they may experience no side effects at all from their use. However, many side effects have been reported from these medications, including rash, anaphylactic shock (sudden unconsciousness or death), slowed heart rate, low blood pressure, cold extremities, worsening of heart failure, fainting, rapid heart beats, dizziness, fatigue, headache, depression, sleep disturbances, nightmares, hallucinations, short term memory loss, high or low blood sugar, stomach ache, flatulence, constipation, nausea, diarrhea, dry mouth, vomiting, heartburn, bloating, impotence or decreased libido, difficulty urinating, bronchospasm, cough, wheezes, naal stuffiness, joint pain, and muscle cramps.
- 5. Do beta blockers cause addiction?
Beta blockers do not cause addiction -- which means physical and psychological dependence on a substance that is beyond the user's control. But beta blockers, when used on a regular basis, can cause physical dependence.
Physical dependence is when the body becomes accustomed to having a medication in the body, thus over time, more medication is required to achieve the same effect. It also means that if the medication is suddenly stopped, the person can experience a rebound in the symptom the medication was being used to treat.
Not all medications cause physical dependence. To develop physical dependence, the medication must be used on a chronic basis.
In the case of beta blockers, physical dependence is not usually an issue when they are used for stage fright, as they are used in low doses and are not taken on a chronic basis. When beta blockers are taken on a chronic basis, as for high blood pressure, suddenly stopping them can cause a severe, dangerous elevation in blood pressure that could lead to a stroke or heart attack.
Addiction causes the person who drinks alcohol, abuses a medication, or takes an illegal substance to exhibit substance-seeking behavior, perhaps even committing criminal acts to obtain it.
What makes this issue confusing is that alcohol, narcotics, cocaine, and amphetamines can cause both physical dependence and addiction, and usually both must be treated at the same time. Beta blockers do cause physical dependence when used on a chronic basis, but it would be highly unusual for them to cause addiction.
- 6. Will beta blockers help my performance?
The answer varies greatly among individuals. Obviously, if you have a medical condition that makes beta blockers dangerous for you, they will not help.
Beta blockers don't make you play better by themselves; they just relieve physical problems resulting from the fight or flight response. On the other hand, some musicians feel that adrenalin helps their performing, giving them an edge that adds intensity to the performance.
Beta blockers have not been shown to directly improve a musician's emotional state, except to the extent that some musicians feel better when their physical problems are relieved. If your performance anxiety shows itself mainly in psychological ways (e.g. negative inner voices), beta blockers will not help you.
The scientific studies and articles we looked at clearly show that beta blockers significantly reduce symptoms that can hinder some people's playing. The musicians in the studies said they felt better about their performance after taking beta blockers, and music critics consistently judged their performances to be better.
Be aware, however, that one article raised the concern of whether beta blockers help only technical aspects of performance, but may in fact diminish emotional elements.
A note about dry mouth: Anecdotal reports show that some musicians who've tried beta blockers say they don't help dry mouth, or can even make it worse. In our research, however, we found a study that conclusively showed beta blockers to help dry mouth among brass players.
- 7. How many musicians use beta blockers?
A study reported in 1986 of 2,122 musicians in major U.S. symphony orchestras showed that 27% reported taking beta blockers. Of that 27%, 19% took them daily under a doctors prescription for heart conditions, etc., 11% had a prescription for occasional use (concerts, auditions, etc.) and the remaining 70% reported occasional use, but without a doctors prescription. (Again, these percentages are of the 27% who reported taking beta blockers, not of the whole population.)
When the musicians who took beta blockers for medical reasons are factored out, slightly under 22% of musicians in this study reported using beta blockers occasionally, with or without a prescription.
Among those who reported occasional use, with or without a prescription, the events they said they used them for were: Auditions, 72% ; solo recitals, 52%; difficult orchestral performances, 50%; concerto performances, 42%; before every performance, 4%.
In our highly unscientific survey based on the FLUTE Internet mailing list, there were 103 respondents total. Of these, 24 (23%) said they use or used beta blockers, 79 (77%) said they didn't.
Of those who called themselves professional performers and/or teachers, 52% said they used beta blockers, 48% said they didn't. Of those who called themselves students, amateurs or non-professional teachers, 2% said they used beta blockers, 98% said they didn't.
- 8. How does the music community view the use of beta blockers for performance anxiety?
As you might expect, opinions vary widely. Here are what a few well-known musicians have said on the subject:
Trevor Wye, flutist and teacher: After saying that beta blockers "should seriously be considered for important occasions," he writes: "Readers who may have some misgivings about the use of alcohol or drugs may care to reflect on the effect of nerves and strain on the body which can cause a great deal of damage over a period of time." From "A Trevor Wye Practice Book for the Flute, Volume 3: Articulation," (Novello & Co. Ltd., Borough Green, U.K., 1983).
Geoffrey Gilbert, flutist and teacher, as quoted by biographer Angeleita S. Floyd: "[Gilbert] did not advocate the use of [beta-blocker] drugs or alcohol for controlling nerves in performance....Gilbert's reasoning stemmed from the fact that although they may work, one can easily become addicted." From "The Gilbert Legacy" by Angeleita S. Floyd (Winzer Press, Cedar Falls, Iowa, 1990).
Mary Stolper, flutist and teacher, tours with Chicago Symphony Orchestra: "I have never taken [beta blockers] and my one brother has never taken them. But my other brother swears by them. I think it's a very personal choice. "I don't give them to my students. If they come and we talk about it, I'm not going to stop them from taking them. I probably would encourage them to take them if they're curious about it; go ahead, take them and see. But don't take them for the first time on your first audition! "Taking the audition is so difficult, the odds are so against you to begin with, if that little thing makes you think you've got an edge, why not?....But I don't think it's ever been proven that they help." From a taped interview with K. Harby, January 1997.
Stuart Edward Dunkel, oboist and composer: "The use of drugs in controlling symptoms of fear felt at an audition should be thought out carefully. The underground musician's drug, Inderal, is in widespread use today. However, one should use caution by understanding the side effects of a given drug and by realizing that an addiction to drugs may occur and that this may therefore not be the ideal approach to the problem of stage fright." From "The Audition Process: Anxiety Management and Coping Strategies," Juilliard Performance Guides No. 3 (Pendragon Press, Stuyvesant, New York), 1989.
- 9. What other approaches are helpful for dealing with performance anxiety?
Because the fight or flight response occurs only when we perceive danger, it can be avoided or minimized if we can convince ourselves there is nothing to fear. This is the goal of many non-medication approaches. The physical sensations of fear can also be managed in specific, non-medication ways.
There are many books and articles that may help you understand your stage fright and manage it. Some of the following are, unfortunately, out of print. If you are unable to find any book in your local library, ask your librarian, who may be able to obtain it from another library.
* "The Audition Process: Anxiety Management and Coping Strategies," by Stuart Edward Dunkel (Juilliard Performance Guides No. 3, Pendragon Press,Stuyvesant, New York, 1989).
* "A Soprano on Her Head: Right-side-up Reflections on Life and Other Performances," by Eloise Ristad (Real People Press, Moab, Utah, 1982).
* "Making Music for the Joy of It: Enhancing Creativity, Skills and Musical Confidence," by Stephanie Judy (Jeremy P. Tarcher, Inc., Los Angeles,1990).
* "The Inner Game of Music," by Barry Green with W. Timothy Gallwey(Doubleday, New York, 1986).
* "Anxiety and Musical Performance: On Playing the Piano From Memory," by Dale Reubart (Da Capo Press, New York, 1985).
You can also try eating dairy products and turkey, which are rich in substances that are known to enhance relaxation. Some flutists recommend bananas. Nicotine and caffeine can contribute to shakiness and anxiety in some people.
Biofeedback, yoga, relaxation techniques, and cardiovascular fitness are recommended in the books listed above. Classes and seminars exist in most communities that can help you with any of these activities.
Cognitive therapy, the area of psychotherapy that holds that your understanding of a situation can change your emotional response to it, is often sought by people with stage fright. Hypnosis may also used. If you decide to seek a therapist, try to find one who is experienced in treating anxiety disorders, and especially one who has experience treating performers.
Published here with the kind permission of Karla Harby.
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