Beta Blockers and Performance Anxiety

Edited: November 17, 2017, 4:06 PM ·

Dear musicians,

For my studies I am writing a research about the use of beta blockers (propranolol, inderal) by musicians. There are already some blogs on this website about this particular subject, but most of them are several years old, and could be a bit outdated.

That's why I would like to ask you if you use, or have ever used, beta blockers for performances and/or auditions, in order to reduce the nerves.
What are your experiences?
Have you experienced any negative side effects?

If you don't want to take them, please explain why not. Do you think beta blockers are harmful, or give people an unfair advantage in auditions?
Also, do you think there is a taboo on this subject? Is it difficult to talk about beta blockers with other musicians?

Replies (119)

November 17, 2017, 6:25 AM · You mean, like, performance enhancing drugs? :-)
November 17, 2017, 6:53 AM · You will probably get more and better responses if you give people a way to respond to you privately.
Edited: November 17, 2017, 7:18 AM · I don't take them, never did. The literature I've read is largely against their use -- unless you have a medical condition that requires them.

I've played since I was a kid -- back when I'd never heard of beta blockers. Like most new players, I had to confront nerves and learn how to deal with them; but I found very early that, once I dug in and just started playing, having prepared to the best of my ability, the adrenaline burned off, and I was able to transmit the music. Performances and auditions became events I looked forward to.

These drugs typically slow heart rate and circulation. That's something you definitely don't want to have happen -- especially when you need warm hands and secure traction. There are plenty of other negatives involved -- the old threads list more than I need repeat here.

Bottom line: Do you really want to confront the problem of nerves and deal with it? Or would you rather just find "a way around it" and take the easy (?) way out?

I like knowing that, whatever performance I can give, it's really me, in full possession of my faculties, not propped up by chemical assistance.

November 17, 2017, 8:09 AM · I have the same opinion as Jim
November 17, 2017, 8:11 AM · "Also, do you think there is a taboo on this subject? Is it difficult to talk about beta blockers with other musicians?"

As far as this site is concerned, it's not taboo, since the subject has come up fairly often and evoked robust debate and strong views on both sides. No idea how much discussion there is within the music industry as a whole, since I'm not in this field.

Can't speak for the next person, but I, personally, don't find it difficult to talk about beta blockers with other musicians. But then I don't recall ever being the one who brings up the subject. When someone else brings it up, I'm happy to join the discussion and offer my views.

November 17, 2017, 8:32 AM · I've tried them now and again over the years. Do they help? It's hard to say, actually. I have to wonder if there's significant placebo effect. The amount taken for a performance is insignificant relative to a therapeutic level, so I think the simple act of driving on the freeway to a the gig is probably more dangerous. One thing I would NOT do is to try increasing the dose if you feel you're not sure it's working or if you want a greater effect. They did cause dry mouth for me. I don't think it decreases anxiety per se, but rather slightly dulls the physical effects. Whatever the effects, I thought they were subtle.

I think the OP should narrow the focus to research on beta blockers vs a placebo.

Edited: November 17, 2017, 1:49 PM · You can probably find everything I written on line about beta blockers/performance anxiety/essential tremor by googling "beta blockers Andrew Victor"

I first learned about beta blockers of "stage fright" 40 years ago at a roundtable of "performance professionals" and have taken them (with doctors prescriptions) for every solo or small chamber ensemble since and more recently I have used them to suppress "essential tremor" of my right hand, even for some rehearsals or solo practice. The reason for it working in that latter case is totally different and may not be understood.

There probably can be a major placebo effect for performance anxiety in some people, but not with the first effective use. I know of at least one user who having discovered that they worked for him was able afterward to solve his problem without them.

Edited: November 17, 2017, 10:05 AM · Personally, I'm opposed to the idea of taking drugs for anything other than treating a health condition. I suppose one could call performance anxiety a mental health condition, which makes it a grey zone, but if that is the case, it should be prescribed by a physician if drugs are necessary. In such case, hiding the symptom (fast heart rate) may not be the proper thing to do. Part of learning to play music, is learning to perform (generally). Popping up pills isn't learning!
Edited: November 17, 2017, 11:33 AM · The thing is, beta blockers are indeed prescribed to treat a specific medical condition: one that causes an excessive (beyond normal) level of physiological reaction to stress (for example, values for heart rate, sweating, and tremors that are beyond what a baseline "normal" person might experience that interferes with a person's ability to even hold their instrument up). Beta blockers don't eliminate nervousness...all they can do is minimize the issues so that a person can be closer to normal. If you've ever known anyone that has taken them or have taken them yourself, realize that there is no real "performance enhancement" aspect to them at all. They can't make you play better in tune, have more accurate rhythm, or generate an interpretation.

I had a private student once (college age) whose involuntary shaking and ridiculous levels of sweating made it nearly impossible for her to play. She had tried everything, including the meditation, yoga, tons of practice and preparation, bananas, you name it. For her, taking beta blockers some of the time allowed her to pursue music-making normally like everyone else. I'll admit this is the only case I've seen in the past ten years; unfortunately the stigma about it pretty much drives discussion about it underground.

This attitude that people should never resort to them reminds me of the folks that look at people with major/clinical depression and say, "you don't need medicine, why can't you just cheer up?"

I'd recommend everyone take a look at a discussion on this topic from the Clarinet board, which has a lot of useful commentary from a number of players, including Gregory Smith, currently a member of the Chicago Symphony Orchestra: LINK

November 17, 2017, 11:48 AM · Agree with Gene 100%.

My audition days are long in the past, but when I was on the circuit, a significant percentage of musicians were taking them for auditions. They are not a magic pill; in the best case scenario, they allow a musician to play at or close to that musician's true level.

Anyone wishing to use medication for performance anxiety should consult a doctor as there are some medical conditions that contraindicate the use of beta blockers.

November 17, 2017, 1:06 PM · Knowing that Beta Blockers or anti-anxietal meds (like xanax) existed back when I was 16 and 17 would have changed the entire trajectory of my career choices. I worked so hard to do well on auditions and COMPLETELY bombed every single one due to horrible, horrible nerves. Like, physically shaking, shallow breaths, light headedness, etc....

Mary Ellen, no offense, but to me, they would have been like a "magic pill." To have ANY reduction in my incredibly horrible nerves would have been outstanding. I'm not saying I would have gone and become a professional as a result of them, but I would have at least done better than 10% of my normal capacity at auditions.

So now I'm a teacher :)

With that said, I have never taken them, because as a teacher, it really isn't necessary. Maybe someday if I have any performances I'll check them out.

Edited: November 17, 2017, 7:33 PM · No, I never have taken any pill for anxiety of any kind,even though I have suffered from anxiety attacks on and off for many years and I am always extremely nervous during solo or chamber performances. Dependence on medication should be the very last resort. This is what my doctor and I (a former oncology nurse) firmly believe. Anxiety alone won't kill us. There are all sorts of way to cope and that's what choose to do, such as, get to know the patterns when it occurs, using CBT, simple breathing technique, realistic expectation of outcome s, etc.

Edit: The bottom line is, I believe that each time I take a pill to deal with anxiety, each time I have robbed myself the opportunity to learn how to understand and handle it medicine-free.

Edited: November 17, 2017, 2:04 PM · As one who has experienced horrible anxiety in both public playing and public speaking environments, I'd recommend a tiered approach to overcoming such things, over drugs.

One thing which helped me a lot was a gradually increasing level of exposure and stress.

On the public speaking front, this started with small groups (two to ten people) which in hindsight, I was really bad at, at first. But since these were volunteer jobs, they put up with my learning curve.

At the moment, I might be OK speaking live to a national TV audience, but I have no way of knowing, since I have never done that.

I have before recommended "busking", as one method to push beyond past performance anxieties.

November 17, 2017, 1:53 PM · Try reading "Sticking It Out," by Patti Niemi, memoir of a professional symphony percussionist whose entire professional career has depended on beta blockers.
Edited: November 17, 2017, 2:06 PM · Well I can’t really say anything because I never had any serious nervousness issues.
I remember one performance, as a kid, when my whole body just froze like a rock and I was observing my fingers moving by themselves during performance, but that’s about it :)
In the last few years, I still got some unvoluntary shaking/sweating/lack of focus issues, especially in big competitions/important concerts, but those went away with experience. Now I approach concerts and auditions like any other thing!
And regarding beta-blockers, I would only take them if absolutely necesary, such as in the case where all else failed. Why use crutches when you can just heal your leg?
November 17, 2017, 2:15 PM · Beta blockers are "equalizing/levelling drugs", not "performance-enhancing drugs". I was completely unable to perform as a younger teenager due to anxiety which resulted in shaky bow arm, but beta blockers brought me to the level of people who did not have this problem. I probably would've had to quit otherwise - had tried everything from bananas to therapy. It is a legitimate medical condition, and while you should try other things first, sometimes people really do need medicine to continue performing.

By the way, beta blockers do not get rid of all the mental anxiety, they mostly prevent physical symptoms.

This is certainly not a matter of placebo effect - medical doctors have prescribed them for years as legitimate medicine. They lower blood pressure among other things. I have not yet found a doctor who wasn't on board with them.

I have found it to be a taboo topic among students who don't get nervous.

November 17, 2017, 2:33 PM · Erik, by "not a magic pill" I mean that they will not help anyone to play better than that person's normal best playing. You still have to do the practicing. I agree that the effect can be transforming for someone suffering from severe performance anxiety.

I have used beta blockers for extraordinarily stressful situations (auditions in the past, the occasional solo performance) because those are out of my norm and I don't do them enough to become desensitized. I do not use them for my normal (orchestral) playing.

I do think students need to try non-pharmaceutical methods of coping with performance anxiety first. Beta blockers should not be the strategy of first resort.

Edited: November 17, 2017, 2:51 PM · Gemma wrote:
"Beta blockers are "equalizing/levelling drugs", not "performance-enhancing drugs". I was completely unable to perform as a younger teenager due to anxiety which resulted in shaky bow arm, but beta blockers brought me to the level of people who did not have this problem. I probably would've had to quit otherwise - had tried everything from bananas to therapy."

So you just kinda gave up, early on, rather than exploring the multitudes of other options?

November 17, 2017, 2:50 PM · To clarify, I got beta blockers at age 17; I first experienced this crippling performance anxiety at around 12. That's 5 years (at an intensive music high school with many performances) of trying to make it go away without medicine.

As I said, I explored everything from bananas to therapy.

Edited: November 17, 2017, 3:28 PM · Yeah, well, I was experiencing things from severe arthritis, to Touretttes syndrome, to severe performance anxiety by the age of 18 (some of these things manifested much earlier). Despite all that, I've still managed to be somewhat successful, pushing into 65 years of age.

Stop making excuses, step up to the plate, and show what you can do. In the real world, actual performance capability matters a lot more than excuses.

Edited: November 17, 2017, 3:19 PM · Lol, I feel for Gemma, she’s new on this forum, and the poor girl is getting sacked left and right :D
November 17, 2017, 3:26 PM · It's a medical condition which has been solved with medicine. And it's my body, my career. Stop taking things out on young people just because you think you've had it rough.

If you're looking for a punching bag, I'm not going to give you that.

November 17, 2017, 3:26 PM · I think using the beta blockers at the discretion of a physician is fine. In general people are more open to antidepressant because so many people are using it nowadays. Beta blockers are not steroids, and who knows? In addition to anxiety control, you may also receive the benefit of reducing the risk for heart attack as well by taking beta blockers. Two birds with one stone, I think.
November 17, 2017, 3:28 PM · Yeah, you wouldn't tell a depressed person to "stop making excuses" unless you're highly uneducated, so I don't really see where anxiety differs.
Edited: November 17, 2017, 4:09 PM · Gemma wrote:
"It's a medical condition which has been solved with medicine. And it's my body, my career. Stop taking things out on young people just because you think you've had it rough.

If you're looking for a punching bag, I'm not going to give you that.

Sure, it's your body and your career. Some people have offered good advice on what to do along both lines. (Two threads now)

If you think that some people are "taking things out on young people", I'd advise another look. We have all been young. Fewer of us have been old, and career experienced, with both perspectives. I've mentored plenty of highly successful younger people.

If your goal is to "stick your head in the sand", few of us can help you. Your attitude, and approach to continuing learning is highly important.

Edited: November 17, 2017, 4:08 PM · Holy projection, David!

"In the real world, actual performance capability matters a lot more than excuses."

Sounds like Gemma found a way to improve her actual performance capability, just not the way you want her to.

With respect to beta-blockers, they are capable of some side-effects, and it's always good to know what you are getting into.

Edited: November 17, 2017, 4:22 PM · Christian, can't rule that out. But in my admittedly limited experience, medications have seldom been the best substitute for addressing underlying problems.

I've done a lot of social work over the last 20 years, with people recovering from trauma, or something akin to post traumatic stress disorder. So I'm not coming from a position of total ignorance.

Edited: November 17, 2017, 4:24 PM · This post is a survey, and I was simply answering the questions. I did not ask for advice.

Anxiety is not a product of teenage immaturity, it is a debilitating medical condition. Anybody who thinks people who take medicine are "sticking their head in the sand" or "making excuses" has clearly not been through this type of thing.

Also, medicine is demonized far too much. It is a legitimate solution to a problem which would've otherwise ruined any potential for a career. Beta blockers are not dangerous as long as you consult a doctor & get the necessary blood pressure test (which is compulsory in my country, as you need a prescription). So I really don't see why people are so against it.

Edit: just saw post about underlying problems. It is of course important to sort those out, but sometimes you need years to do that, and a musician obviously doesn't have that sort of time. For me it's a work in progress.

November 17, 2017, 4:26 PM · As much as I hate to disagree with David, I feel it's necessary here. Some people really do need meds to perform their best.

With that said, the best "natural" way of reducing performance anxiety is to start playing EVERYWHERE. In public. In front of Wal-Mart. At the bus stop. For literally ANYONE willing to listen. Especially play in front of people that DON'T want to hear you. Put yourself in these somewhat embarrassing situations and ACCEPT the feeling of self-consciousness. Get used to it, and know it's part of you. And once you're used to playing with your self-consciousness sitting beside you, in plain view, then playing in front of people will be much more doable. You'll still probably play better with a touch of Xanax, though, because the nerves will always be there a little bit. It's just a matter of your own principles on medication and such.

So in a sense, you are both correct. I think utilizing both natural methods combined with the minimum amount of meds necessary is the ideal approach, personally. For some, that might mean no meds at all, and for others it might still mean taking quite a bit, even after a tiered natural approach.

And David, I had pretty bad Tics growing up, too! (Of course I was never bad enough to repeatedly yell "F***" in public or anything of that nature.... more like unstoppable, repeated twitches and throat clearings).

November 17, 2017, 4:28 PM · Gemma wrote:
"This post is a survey, and I was simply answering the questions. I did not ask for advice."

You didn't realize that when you post on a public forum, you get what you get, regardless of what your "control" intentions may have been?

Edited: November 17, 2017, 4:36 PM · That's fair, David. I personally would probably not take blockers unless it was for a non-performance condition (some of those side-effects sound too funky for me). I have found meditation, lifestyle stuff and just performing more to be a fairly reliable solution, but I try and keep my performances towards the low-key.

I'm also partial philosophically to the idea that beyond a certain amount of natural stage anxiety, a bad reaction is pointing either to flaws in my technique or in my preparation. Of course, professional musicians are usually under greater constraints than I am. I tend to give people the benefit of the doubt when they say that the drugs work for them, but the entirety of my experience with them is other peoples' anecdotes.

November 17, 2017, 4:40 PM · I would add "being too self-critical" to that list, but that's a good point.
Edited: November 17, 2017, 5:38 PM · Coming from a medical background (a GP mother and a general pathologist husand in addition to my own nursing background), I would be the last person who is against medicine. Taking beta blockers once in a while before performance may not be a big risk in most cases; however, generally speaking, the risks of taking medicine prescribed by doctors cannot be overstressed.

Dear Gemma, I sincerely hope you can see love in people who tell you something that is not positive or affirming. Depending on medication at any age but particularly at as a young age as yours does cause legitimate concern. Of course we are not your doctor nor your parents, but I hope what people have cautioned you will bring you some healthy doubt about the wisdom of medicine-dependence in dealing with performance anxiety. I trust you can see that there is no ill intention in anyone's comments here.

November 17, 2017, 5:42 PM · I am genuinely struggling to see *why* dependence (not addiction) on medicine is worse than, say, dependence on eating a banana. It would be very helpful if one of the people here who say it's a bad thing could explain it.

November 17, 2017, 6:42 PM · Dependence on things external to our own mental, physical and creative resources is not desirable and I guess that's a key idea behind David's comments. I believe that each time I take a pill to deal with anxiety, each time I have robbed myself the opportunity to learn how to understand and handle my anxiety. Depending on medicine has risks of known and unknown long-term side affects that fruits like banana doesn't have, as far as we know. However, a more productive conversation of long-term side effects of any medicine is one between you and your doctor.

Here in Canada, we are not pressured by pharmaceutical companies to push for medication, but many patients would feel if their doctor gives them something to take, their problem has been taken seriously. I can see why doctors are conscious about not to over-test or over-treat patients can get unfair bad reviews. But these are the doctors I seek out. I'm not an expert on the risk of over-treatment, but a good doctor should lay out all the options before giving their patients medication. The best doctors in my book is the one who promotes guided self-care and who encourages me to control my own physical and mental health whenever I am still able before giving me pills, which should be absolutely the last resort.

Personally, I had experienced anxiety attacks since I was in my late 20s. When my late husband passed away a few years ago, my anxiety and depression got so bad that once I had to be brought to an emergency room. After many tests and consultations with doctors and psychologists, we came to the conclusion that healthy living combined with cognitive behavioral therapy was the best approach. It took time to see result but it worked.

November 17, 2017, 7:01 PM · Thank you for explaining that.

I also see the benefit of more natural methods, and did spend several years trying them (therapy, bananas, meditation, daily exercise, diet...). The GP who prescribed my beta blockers asked if I had tried those methods first.

In terms of risks, my doctor did not seem to think there were any long term side effects of beta blockers, except maybe a reduced risk of heart attack.

November 17, 2017, 7:26 PM · According to Mayo Clinic (

Side effects and cautions

Side effects may occur in people taking beta blockers. However, many people who take beta blockers won't have any side effects.
Common side effects of beta blockers include:
Cold hands or feet
Weight gain
Less common side effects include:

Shortness of breath
Trouble sleeping
Beta blockers generally aren't used in people with asthma because of concerns that the medication may trigger severe asthma attacks. In people who have diabetes, beta blockers may block signs of low blood sugar, such as rapid heartbeat. It's important to monitor your blood sugar regularly.
Beta blockers can also affect your cholesterol and triglyceride levels, causing a slight increase in triglycerides and a modest decrease in high-density lipoprotein, the "good" cholesterol. These changes often are temporary. You shouldn't abruptly stop taking a beta blocker because doing so could increase your risk of a heart attack or other heart problems.

November 17, 2017, 7:43 PM · "Anxiety is not a product of teenage immaturity, it is a debilitating medical condition..."

True. And with music, anxiety can strike anytime and anywhere. One can go for years without it, and then it rears its head. So I would say to people that think its some kind of moral failing to have to take them:
What should one do when playing your best is the difference between getting a job or not? Being fired or not? Should a tiny tremor or a moment of anxiety sink a career? I think if someone needs them, try them.

Edited: November 17, 2017, 7:48 PM · Gene has a good point, as always. Except that performance anxiety and depression are two different conditions so one has to treat them independently and carefully. Sever depression can kill people, unlike performance anxiety. Anxiety and depression can be related, but depending on the severity of the condition and general health condition of the patient, whether and which medicine should be taken.

Edit: just saw Scott's post. I agree. When the stake is so high as to lose one's job or career development, some compromise has to be made, as the last resort. It's not a moral failure. It's not even a failure of any sort; it's just life.

November 17, 2017, 7:56 PM · Oh whoops, I totally forgot about those side effects (probably because I never ended up experiencing them). Yeah, thats definitely a downside for people who get them.
November 17, 2017, 8:50 PM · I've taken beta blockers for a few weeks for medical reasons. The side-effects were a major problem for me. However, that was at a much higher dose than is used by performers.

There are two sides to performance anxiety -- the mental and the physical. Everyone has to learn to deal with the mental issues. But the physical issues do not strike everyone with equal force. Some of the physical issues can be mitigated by technique. Some can't. Some of the extremity of the physical issues lessen with time and habit -- the body doesn't panic as much, so to speak. But some doesn't.

I do a lot of professional public speaking. I'm mentally calm and prepared, and I've gotten better with every passing year, but some bit of irrational fear makes my hands really, really cold on stage, to the point where I can have trouble handling the clicker. Training and experience has helped me to not speak too quickly when nervous, for instance, but absolutely nothing has helped the cold hands.

I've found something similar with my violin-playing. I can be calm and prepared, but the physical symptoms are quite unpredictable. I've found that I can dramatically reduce the feeling of nervousness by taking a chewable Alka-Seltzer, a few hours before the performance, and a second tablet about an hour before if my stomach still feels unsettled. If my stomach is calm, I'm much less likely to get cold hands. If the performance venue is warmer, and I'm able to keep my hands warm, I'm much less likely to get cold and shaking hands. I've found that I can have a normal heart rate and yet have hand shakes from the adrenaline.

My teacher has helped me to make technical modifications that make it less likely that my hands will shake in performance, and to try to rapidly mitigate the symptoms if they appear. That's valuable, but in a truly high-stakes situation, I wouldn't want any chance of even a problematic second.

For some of my amateur friends whose nervousness has prevented them from performing, a beta blocker has enabled them to enjoy performing, every once in a while. For professionals, plenty quietly use beta blockers in high-stakes situations. Orchestra auditions absolutely count.

I've never taken beta blockers for performance. I'd certainly like to try, but they would interact with other drugs I take for medical reasons, so I can't.

Edited: November 17, 2017, 9:26 PM · Sorry, but to me taking beta blockers to calm down my heart rate caused by anxiety is akin to drinking alcohol or shooting cocaine to forget about every day issues. It doesn't address the problems, it merely hides the symptoms. I have to take beta blockers every day for an underlying medical issue, and believe me, it is not the solution, and I much rather not. Anxiety is a psychological issue. I personally have a great deal of stress when performing in front of others, including my teacher, and the beta blockers I take, every day, do not help in any way feeling better. Yes, my hearth rate is low, but I am still nervous, still playing lousy, still not performing as I know I can.

November 18, 2017, 1:12 AM · I agree with Lydia that performance anxiety is both mental and physical, but one should keep in mind that the physical stems from the mental, and if one takes care of the mental side, there won’t be any physical problems.

Last year at Uni I took a class called ‘Physical and Mental Preparation of the Musician’.
I learned a lot, about a huge number of different things, but if I had to choose just one thing that could help the folks out there with performance anxiety, it would be visualization.

What is visualization? Basically, you just completely relax your body with breathing techniques and whatnot, and then you fully picture, in great detail and from beggining to end, an upcoming performance. You picture the hall where the performance will take place, the audience, how you go out on stage, how you play, how you feel while you play, etc.
You do that several times, as much as needed, in the weeks, or months preceding the performance.
The caveat is that, just like for mental practice, the brain does not make any dinstinction between actual and imagined events, so ‘practicing’ performance like that greatly reduces, or completely eliminates anxiety on the day of the actual performance.
And the great thing, is that you have complete control over everything that happens as it is imagined, so you can picture whatever you want :)

One guy in the class tried this technique for his end of year exam. He had a history of bad performance anxiety. He visualized his exam about 7 times in the few weeks before it, and he said that on the day of the exam, he felt absolutely calm and relaxed, and had no anxiety problems. In his words, he had already been there and had already done the exam 7 times, so this was just like doing it again for the 8th time.

I’m not very good at explaining, so sorry if you are left confused. but I strongly recommend that those of you who suffer from performance anxiety try this technique. It is widely used outside the musical sphere in sports, business, etc, and progressively starts to be used within the classical music world as well. There are infinite ressources you can find on the Internet on the subject.

Edited: November 18, 2017, 5:03 AM · My family ran across a really cool video "A day in the life of" cellist Johannes Moser where he works with a mental coach using this visualization technique leading up to a performance of the Lalo,

My 12 year old cellist daughter is a huge fan now :-).

I'm not sure why some folks are so vehemently against medication especially when used in conjunction with some cognitive approach. Individuals are "wired" differently with a significant inherited aspect to this. It's not a failing or a choice, and often it's just the flip side of other traits that lead to success.

November 18, 2017, 5:15 AM · There seem to be a few misconceptions evident in this discussion. Beta blackens are not anti-anxiety medications or antidepressants, they don’t work in the brain. The Beta in the name refers to receptors all over the body which respond to Adrenalin in the circulation, the blocker part means the molecule blocks or modulates the effect of Adrenalin on the Beta receptors. Adrenalin is a substance the body produces to prepare the body for “fight or flight” situations. The Adrenalin effect that would be perfect for a running back waiting for the football to be snapped would be totally disruptive for a violinist waiting for the conductors first downbeat. The fine motor control needed for making music is changed by Adrenalin to coarse shaking activity needed to power thru combat-like activity. This effect of Adrenalin is what is modulated by beta blocking medications. Even people who don’t feel anxious before a performance may experience this loss of fine control due to circulating Adrenalin. Why some people experience this effect more than others is a mystery. But certainly if a performer begins to feel the bow shake the body’s response can be “I’m in trouble now” and more Adrenalin is released exacerbating the problem. This is the natural response of the body to perceived threats. Can non-pharmaceutical methods work? Certainly. If a violinist begins performing in public at an early age then debilitating shakiness may never develope.

Here’s my main point, why does this topic always create so much vitriol, so many violinists condemning other musicians for the way they deal with their personal physiology? Such a feeling of superiority among some when given the chance to find fault in others? Using a beta blocker is not equivalent to taking a good stiff belt of Scotch to calm one’s nerves before a performance as others seem to suggest. Frankly as a violinist and a doctor, I don’t feel it is any of my business how others prepare for performance. I don’t care to rake others over the coals because they’ve found an effective way to control their physiology. I enjoy music, not prying into the personal affairs of musicians.

November 18, 2017, 5:26 AM · Glenn, thank you for the insight into the process and much needed words of wisdom.
November 18, 2017, 5:53 AM · I read a interesting article the other day about the constant fight for dominance which plagues our world nowadays, and how it causes the fight-or-flight-or alternatively the freeze-response in our bodies, and how repeated exposure to it can lead to vicious cycles and devastating results on our health, both mental and physical.

One of the many propositions of the article was to view our life not as a constant struggle for dominance, but rather as a constant cooperation with others, one where people strive to achieve win-win situations, for everyone’s greater good.

I observed an interesting thing in conversations with others these last few days: someone would say something that would rub me the wrong way, and I would feel the rise of the adrenaline throughout my body to give me the energy to fight and defend myself against this verbal attacker. But instead of giving in to it and fighting back, I would just recognize this physiological response, notice what caused it, and realize this is just my ego trying to hold onto its pride. Just doing this, cancelled the fight-or-flight response.

What I’m trying to say, is that it’s all a matter of perception. If you perceive auditions, concerts, or any kind of performance as a fight, an event where you ‘have to play well’, ‘prove how great you are to others’, ‘impress everyone with your perfect intonation’ or whatnot, in short if you perceive performances as an event where you have to prove your worth on the dominance scale and fight to maintain your position, or get to a higher one, then sure you will get nervous and maybe need to use beta-blockers!

But if you see performance as a form of cooperation instead, one where you just want to share something beautiful with the audience that came to listen to you today, inspire and get inspired, and travel all together to another dimension, th4 beautiful alternate dimension of music, then I can assure you the fight-or-flight response will never get activated.

Pay attention to how you perceive and frame your performances. With the right mindset you will never need to use beta-blockers.

November 18, 2017, 8:59 AM · "Beta blackens are not anti-anxiety medications or antidepressants, they don’t work in the brain..."

You may be medically correct, but I still believe that there is a psychological component when you know you have just swallowed a pill before a performance. If we can, as Roman points out, calm ourselves with mental preparation or meditation, we can also calm ourselves if we think we have just taken a drug.

"He visualized his exam about 7 times in the few weeks before it, and he said that on the day of the exam, he felt absolutely calm and relaxed, and had no anxiety problems."

I don't doubt it. However, taking an exam is different than playing the violin. You can miss 10% of exam questions and still get into medical school. But imagine being in the last round of a symphony audition: you've flown 1000 miles, prepared for 10 weeks, are staying in an expensive hotel, and your friends, family and colleagues all know you're taking an audition. Let's not even talk about your 6 years in conservatory and graduate school, the year spent studying excerpts, and the expensive violin you're paying off. It's down to you and 2 others and all 3 of you play very well. Now it's down to the tiniest intonation error, the tiniest variation in vibrato, the most subtle error in bow control or focus. And if you lose, you have to go home.

That's not like taking an exam. It's another universe of stress. It's probably much more stressful than the actual job. Is it a "crutch" to take a beta blocker? Maybe. But don't make that judgement until you've been through something like what I've described above.

Edited: November 18, 2017, 9:32 AM · I shall point out that this was his instrument exam, it’s a music university.
The benefit of visualization is the same as the one beta-blockers give. It won’t make you play better than you can, so you still have to practice, but it will remove the stress/anxiety which could worsen your performance.
The gist of visualization is acclimation. Something that you’ve done 7 times will not be nearly as stressful as something you have never done before, wether in your head or in real life. And as I already said before, the brain doesn’t register the difference between real and imagined, so while you will consciously know that what you have visualized was imagined, your subconscious will think it was real.
November 18, 2017, 10:01 AM · Do you know what the number 1 fear people have is?

#1 - Stage Fright

Do you know what #2 is?

#2 - Death

That means that most people would rather be in the coffin than giving the eulogy!

Stage fright is real, and can require medical intervention. I have never taken them, but I have no problem with their use.

Edited: November 18, 2017, 10:21 AM · After 49 entries of theory and moralization I guess I should add my own experience, which has been put on line in several places over the past coupe of decades.

I was 17 when my performance was first struck with unwanted right arm shakes. I was not the least bit mentally anxious, in fact it was the the lowest pressure solo performance I had ever done - a could of old-English ditties for my high-school English class. By then I had been playing violin and cello solos around the county for 3 years and had been concertmaster of the high school orchestra for almost 3 years and a cellist in the community orchestra for 2. But there I was shaking over "Drink To Me Only With Thine Eyes." That evening I asked my mother what it might be and she said it was "stage fright," what we also are calling performance anxiety. I figured it was a "one-off," but it happened again the next time I tried a violin solo performance (it was at least another 5 years before it also affected my solo cello performances. Some relief could be had by playing in the upper half of the bow - but that sure limits what one can do.

The only thing I have ever feared when performing has been this stage fright symptom.

I struggled along with this once I resumed public performances of chamber music and some CM solos after college and grad school (about 10 years later). Finally 25 years after the initial event I learned about Inderal (a beta blocker) and got a prescription from my doctor. I think I had a couple of chamber music performances "under the influence" and finally, in my mid-40s I did my first standing-up-in-front-of-the-orchestra solos. I took the Inderal 40 minutes before my solo would start in the 2nd half of the concert, I recall thinking that audience members had probably heard Perlman play this thing "What the H… was I doing." But those mental irritations never caused a problem. I went out and did the performance without a flaw and delighted myself by drawing the bow as close to the frog as possible- something I had not been able to do in performance since my early teens. The d..n stuff really worked.

Over a short amount of time I experimented with lower doses and worked my way down from the original 20mg pills to 1/4 pill, which seemed to work just as well for me. This leads me to think that if someone switched out my 1/4 pill with a placebo, I might never know. (I had some of this pills around in the refrigerator for 10 years before my next prescription and they still seemed to work.) I do have side-effects from even that small dose I take and I have to be careful not to use this aid on successive days or the side-effects compound (more personal experience).

A recent doctor has prescribed a beta blocker to help reduce inessential tremor in my right hand when playing (not just performing) violin or viola, but it is not the same "sure cure" for this different and nearly constant affliction and I usually don't take it. Instead I have adopted a more unconventional bow hold.

I do not have any problems with public speaking, which I had to do as part of my career(s) for nearly 50 years - although the first time (at a national ACS meeting) was almost a full-body breakdown until I had successfully presented the paper. I overcame that by teaching an adult course for a year - problem solved after the first session of that.

As far as the OP's concern about blogs about the use of beta blockers and performance anxiety becoming outdated - that doesn't happen! Life experience does not become outdated, we just have more of it - more people have it.

November 18, 2017, 10:55 AM · Dr. Kotnik, thank you for clarifying the mechanism of how beta blockers works on human body. I completely agree with you that no one should be condemned for taking medication that is necessary for health reasons, and it is each person's own decision how to prepare for their performance. However, since this is a forum for public discussion, I also feel that it's appropriate for people to express their views freely without being silenced. Sharing different views and questioning certain approach is part of an intellectual discourse. To take such comments as a display of feeling superiority or finding fault in others sounds to me somewhat an overstatement.

It appears that you are pro-pharmaceutical methods in dealing with anxiety. I wonder, for a more balanced discussion, if you would be so kind to also address the risks of such approach? And what advice you might give to your patients who prefer to try non-pharmaceutical methods in dealing with this particular problem? What is a minimum period of such non-pharmaceutical work?

Edited: November 18, 2017, 12:27 PM · Roman, there is a world of difference between taking a music exam (presumably a jury) at a university, and playing a professional orchestra audition. Scott Cole gave a good explanation, I think, but you apparently didn't understand it, to judge from your reply.

A pro orchestra audition *is* a fight. It's not a beautiful collaborative thing. You are competing for a job, against potentially hundreds of others who are also highly qualified players. Winning that job is the difference between being able to feed yourself -- or to be able to help feed your family (or afford a family at all) -- and not. The audition process doesn't have all that much to do with the stress of the actual job, but if you cannot play perfectly under audition conditions, then you're not going to be earning a living this way, period.

Under those circumstances, it's not surprising that people take beta blockers to deal with the adrenaline effects. If you take audition coaching from a pro, attend a camp intended to help players prepare for such auditions, etc., the coaches will almost certainly suggest that you consider beta blockers if you need them.

This is very different from more frequent use, although there are certain pro orchestra players out there that take them for every single performance (which will be multiple times a week, in many cases).

November 18, 2017, 12:51 PM · I agree 100% with Scott.

Taking beta blockers for a high-stakes situation is not a moral failing, good grief.

November 18, 2017, 1:25 PM · Lydia, first let me say that I am not arguing against taking beta-blockers if other equally good alternatives are not currently available.
But I do think being dependent on them in the long term is not the most healthy idea.
Let me return to the crutch and leg analogy.

Anxiety problems mean there is a mental problem somewhere/the leg is broken. Depending on the stakes of the event, the anxiety can get ‘better’ or worse/walking around the house with a broken leg won’t hurt as much as running a marathon with a broken leg.
Using beta-blockers/a clutch will successfully help you remove anxiety/pain when you need to win an audition/walk normally.
But if you don’t want to use that clutch for the rest of your life, you better heal your leg.
And in the same way, if you don’t want to be forever dependent on beta-blockers to just be able to play in a decent way and one that reflects your actual playing capabilities, you better learn effective techniques that can successfully replace beta-blockers.

‘But imagine being in the last round of a symphony audition: you've flown 1000 miles, prepared for 10 weeks, are staying in an expensive hotel, and your friends, family and colleagues all know you're taking an audition. Let's not even talk about your 6 years in conservatory and graduate school, the year spent studying excerpts, and the expensive violin you're paying off. It's down to you and 2 others and all 3 of you play very well. Now it's down to the tiniest intonation error, the tiniest variation in vibrato, the most subtle error in bow control or focus. And if you lose, you have to go home.

That's not like taking an exam. It's another universe of stress. It's probably much more stressful than the actual job’

Scott, 2 things:

1.Visualization works regardless of the event’s size. It is being used by top athletes/public speakers with great success. Visualization is not something I invented yesterday, it as an well-established concept has a long recorded history of helping people detach themselves from performance-induced anxiety and enable them to perform at the highest levels.

2.Stress, adrenaline caused by the fight-or-flight response, or rumination or obsessive and negative thinking about the event and it’s stakes will not help you perform better. The goal of visualization is to remove all the aforementioned effects, or at least to greatly reduce their influence.

Beta-blockers fix the physical symptoms. Techniques such as visualization fix the root mental issues. Reminds me of the story about the janitor who keeps moping the floor of the class, when he could instead fix the leak in the roof.

‘A pro orchestra audition *is* a fight. It's not a beautiful collaborative thing. You are competing for a job, against potentially hundreds of others who are also highly qualified players. Winning that job is the difference between being able to feed yourself -- or to be able to help feed your family (or afford a family at all) -- and not. The audition process doesn't have all that much to do with the stress of the actual job, but if you cannot play perfectly under audition conditions, then you're not going to be earning a living this way, period’

Lydia, 2 things:

1.A competitive audition for a coveted job certainly is a fight, but the thing is, you don’t have to perceive it as one.
Seeing it as a fight will not help you play better, and will only lead to inevitable activation of the fight-or-flight responses, which will kill your playing, and your chances of success.
Framing it as something else, an image which won’t activate the fight-or-flight response, can be a game-changer.
I really got into Mixed Martial Arts recently, and observed what made the champions champions, and something I’ve learned from that field is how important it is to be professional about your craft.
If you are worrying about the fact that ‘you've flown 1000 miles, prepared for 10 weeks, are staying in an expensive hotel, and your friends, family and colleagues all know you're taking an audition’ or wether you’ll be able to feed yourself, you are not being professional.
Being professional means being able to detach one’s emotion from the work you do, and to be outcome independent.
If you worry wether you will win the audition or not, then you are not thinking about your playing. And if you let your emotions get in the way of your craft, your playing will be affected.

2.Professional orchestras are not trying to recruit robots who can merely play the notes written on paper correctly. They are searching for musicians, who can actually communicate emotions and inspire people. Approaching an audition as a fight makes you approach it in a very ‘sportive’ way. Play in tune, in rhythm, and with a good sound. Everyone can do that, that’s a pre-requisite, especially in the big auditions. It won’t make you win an audition.
But a musician who can play the notes written on paper correctly, in tune, in rythm and with a good sound AND who can I actually communicate emotions and inspire people, that’s a musician who has much greater odds of winning an audition.
And I think the fight/athletic mentality is maybe not the best place to be if you want to be the second kind of musician.

November 18, 2017, 1:50 PM · Scott and Lydia have explained the nature of a professional orchestra audition thoroughly and accurately.

Do I take beta blockers for my day to day job? No. Did I take beta blockers for pro orchestra auditions? You better believe I did and so did a lot of my competitors. It's an unnatural situation, ultra high stakes, with little relationship to actually doing the job.

For those other than Scott and Lydia who have a lot to say about pro auditions and the moral superiority of those who don't take beta blockers, I would like to know the extent of your personal experience with pro orchestra auditions. It will help me put your comments in context. Thanks in advance.

November 18, 2017, 1:58 PM · Roman, I mean this in the least demeaning way possible: what is your experience with musical auditions and/or the professional music world?

Your #2 point of "not recruiting robots" seems a bit.... idealistic to me. I mean, clearly if a person is both able to play perfectly and expressively without meds, then they'll probably be judged better, but a person with extreme stage fright won't be able to put ANY emotions into their playing because they're consumed by their body telling them they need to escape from the situation. So you'll actually be far more robotic without beta blockers. Also, something like Xanax is more likely to take the emotion out. Beta blockers simply block the specific effects of adrenaline.

I, too, was really into MMA for a bit and while there are a couple of cross-overs between that and music, they are two very, very different things.

I think your advice is useful in general, but in the instance of students with extreme physical symptoms, meds need to be considered. Visualization can only go so far in extreme instances.

November 18, 2017, 1:59 PM · Roman, thank you for your very clear explanation of visualization! I've heard about it a lot and tried it myself, not in such an intensive way that you've described. I'd love to know more about it. You mentioned that the class you took helped you a lot. Could you recommend any reading materials that you used in that class or recommended by your teacher?
November 18, 2017, 2:49 PM · Pro orchestra auditions are extra-weird because they are quite unlike the normal performance and competition situations that violinists are used to. In a performance or competition, the focus is generally on the overall impression of a player, over what can be a pretty lengthy program. A tiny slip here or there isn't quite as important.

But pro orchestra auditions are intensely focused little bursts of perfect playing, behind a curtain. There's no audience energy to feed off, and you get practically no time at all to show what you can do in an artificial, high-pressure situation. Have a tiny wobble of the bow, a tiny extra shake of vibrato in performance and it can easily get lost in the overall impression; in an audition, that might be enough to get you the "thank you, next".

There's no separation of emotion from the technical capability to convey that emotion. And there's zero room to be imprecise. Lingering artistically in a competition can be fine; being at all rhythmically imprecise in an audition is generally unacceptable.

Noa Kageyama (Bulletproof Musician) uses extensive visualization exercises in his coaching, and there's quite a bit of related research and tips on his blog, as well -- recommended reading. Yixi, if you're interested, he offers an online course as well as one-on-one coaching.

It should be noted that there's an extremely high degree of likelihood that most musicians who use beta blockers have already gone through a lot of technical training to reduce the physical affects of adrenaline, as well as plenty of other training focused on reducing the mental stresses of performance. Different people react to adrenaline in different ways, some of which may be debilitating no matter what.

No one feels "outcome independent" when your ability to earn a living depends on your ability to play perfectly.

Edited: November 18, 2017, 3:19 PM · This is important guys, no one here argues that taking prescribed drugs such as beta blockers is a moral failure. Comments in favor of non-pharmaceutical approach shouldn't be equated with moralistic talking. As far as I've seen, non-pharmaceutical approach is focused more on psychological well-beings based on neuroscience rather than morality.

That said, I do feel if I take pill to address my anxiety issue is to choose an easy way out, unless it's absolutely necessary. You may call this a moral statement. But I am not so silly as to believe I would apply this principle in all occasions in my own life, let alone expect others to adhere to it. I hope this is clear.

Lydia, I have read Noa Kageyama's wonderful blogs. Will take a look at his website again for further reading materials. Thanks.

November 18, 2017, 3:19 PM · The online course contains a lot of stuff that's not on his blog. That's why I note it separately. $250, but worth it, I think.
Edited: November 18, 2017, 4:25 PM · Well we are now entering the bigger question of how highly competitive environments can have destructive effects on those who evolve within it.
It’s sad to see the music business has become so sportive. People forget why they are playing music.
What bothers me more than using beta-blockers to remove performance anxiety in an audition, is the after-effect or losing an audition, especially a high stake one where there were lots of expectations as to the result
All the things I say are not to ‘prove mental superiority’ of one thing over another, but to make people aware of the possible negative long-term consequences of carrying specific mindsets.

Let’s say you do that high-stake audition. You prepare your ass off, work like a madman, do all you that’s in your power so you can win the audition, get the job, and feed yourself and the kids.
You flew 1000 miles, you stay at an expensive hotel, and all your friends and family know you are doing this audition. There is a lot of hope, and lots of expectations and emotions, both good and bad, around this audition. You are now going to play in the final round. It’s you versus a couple other players. You have to do better than them. You need to. You just have to win. You have to.
So you play, and you do your best. And you actually do really well, and you are happy with your playing. You prepared so well, for so long. All those years studying the violin, all those years of struggle trying to make ends meet, all leading up to this very moment, the moment where all that hard work finally pays off...

And then you loose.

How do you feel now?

Pretty bad I guess. Like I-want-to-kill-myself type of bad probably.

You lost. It means you suck. Why even bother living then?

What are you going to eat? What are your kids going to eat?

What are you going to tell your friends and family? That you’re a loser?

And most importantly, what are you going to do next, now that you’ve lost?

All that effort, all those emotions, all that money, wasted. Just like that.

For nothing.

That’s what I mean by being outcome independent.
You still follow the process. You still do your best.
But in the first case, losing destroys your life. In the second, not so much.

EDIT: I believe attaching one’s sense of worth, self-esteem and self-love to an external and unpredictable outcome like winning or losing an orchestral audition is not a very healthy thing to do.

Edited: November 18, 2017, 5:01 PM · Mary Ellen said, "Do I take beta blockers for my day to day job? No. Did I take beta blockers for pro orchestra auditions? You better believe I did and so did a lot of my competitors. It's an unnatural situation, ultra high stakes, with little relationship to actually doing the job."

I agree with her. When I performed in the preliminaries of the Montreal violin competition after the Russian who eventually won first prize, I was terrified. I thought I was going to have a heart attack because I had only 15 minutes to prove that I could play the violin.

However, when I played string quartet concerts in a professional string quartet, I rarely got nervous. The same for recitals. However, when once in a blue moon I got to play a concerto with orchestra I absolutely used a low dose beta blocker and did not regret it. I absolutely enjoyed these performances. Those who think that this is cheating are simply wrong.

Roman, what is your experience in performing or taking auditions on the violin?

November 18, 2017, 4:51 PM · For people actually taking pro orchestra auditions, losing is part of the process, honestly. People do auditions for a few years. If they don't win, they have to go with Plan B. There are probably some that do indeed become suicidal, but most normal people go on with their lives -- albeit sometimes with a career switch.

For a player who is fine performing day-to-day, but needs beta blockers to get through an audition, there's no harm done by them doing so; the beta blocker just gives them the chance to play their best.

By the way, people who feel no financial pressure when they take a pro audition, because they'll be just fine financially whether they win or lose -- they've got parents who can continue to happily support them while they find their feet, for instance -- are enormously privileged. I recognize that some significant percentage of violinists are in that position, since it's an expensive thing to get your kids into, but the ability to not feel financially vested in outcomes is for the rarified few who are lucky enough to be born into privilege.

November 18, 2017, 5:14 PM · I agree with Lydia... inevitably to become a musician your parents will have to get their hands on some significant money, one way or another, but to support the child well into adulthood is above and beyond the norm.

So to think of auditions as "playing beautiful music" would be blatantly ignoring the reality, which is a lot harder than it seems.

November 18, 2017, 5:33 PM · Just curious, from those who have gone through formal music program and auditions, does the curriculum includes training aimed specifically at preparing for this aspect of performance? I mean the anxiety associated with performing, or is it just assumed that someone is born with that innate ability to perform with little anxiety and others can't? This seems a pretty significant aspect of becoming a pro performer no?
November 18, 2017, 6:17 PM · This book that I cited earlier in this thread: "Sticking It Out," by Patti Niemi, spends a lot of space on the audition process (years of her time).

Edited: November 18, 2017, 6:28 PM · Anxiety associated with performing is not unique to musicians. It's not uncommon to see lawyers, doctors and professors are struggling with it occasionally or on a regular basis. Unfortunately, nobody teaches you how to cope with stress in professional schools. If music school is different in this regard, well, they are way ahead.

Edith: I just saw Dr. Kotnik's response. Thank you! I am still curious about what you would advise a patient if she, like me, wants to explore non-pharmaceutical route first, guided by experts that you see fit.

Edited: November 18, 2017, 6:45 PM · The main question remains unanswered though:
Why so many musicians have their first traumatic stage episode as teenagers and quickly (often after only 1 episode) develop strong conditioning to fear of performing?
There is no proper explanation why a crowd of music lovers can inspire a fear equal to meeting a predator. A strong biological fight-or-flight-or-play-dead mechanism sets in, when completely unwarranted for and becomes counter-productive to music making.
Knowing all of this from my own experience, and embracing the change of culture (from being a taboo, to openly discussing), why is there no better training for musicians and especially future violin teachers when it comes to stage fright prevention?
So much talent wasted, so many livest lost...
November 18, 2017, 6:58 PM · Sorry, I’m having trouble with my browser posting my response prematurely.

The question was posed as to weather, as a physician, I am pro-pharmaceutical and perhaps against non- pharmaceutical techniques. My answer is to let individual musicians make their own decisions. I don’t see the need for one musician to acuse another of using a “crutch” and implying that they have some character flaw. This discussion has been going on for over 30 years and is now getting a bit tedious for me. The reason beta blockers keep coming up for discussion after so many years is that they are relatively safe, simple to use, few side effects, and they WORK. As Andrew Victor points out so well in his reply, they allow musicians a certain certainty that their solo performance will not be destroyed by shaking arm and fingers. They allow players to perform on stage as well as they perform in the practice room. The placebo effect is well known and could play a part but the elimination of tremor by beta blockers is mainly due to physiologic effect. So effective in fact that the Olympic Committee has banned beta blockers in firearm marksmanship competition because they eliminate tremor which will throw a marksman off target. Of course in Olympic competition the goal is to choose a champion shooter, not to produce targets with holes in the exact center. The targets can in fact be thrown away. In music opposite is, or should be, true, the goal is the production of great music. Perhaps we will reach a point where urine drug tests will be done after every major violin completion. Does taking testosterone produce better Pagannini? Xanax better Mozart?

If someone asked for help with tremor during an audition next week, I’d prescribe propranolol. If someone wanted help with shakiness or “butterflies” on an ocasional, ongoing basis I would suggest biofeedback or visualization-relaxation, both of which are effective in a variety of situations. For musicians, where even slight tremor is very disruptive, it might make sense to start a beta blocker and biofeedback and then taper off the beta blocker over a period of months if the musician agreed. Still, I think beta blockers are more popular among musicians than is commonly realized because of the certainty they offer on specific occasions. Most of the possible side effects of beta blockers are related to chronic use, as for hypertension or migraine headache prevention. A musician must realize that decreased exercise tolerance and fatigue can occur even with a single dose, and the severity of symptoms is directly related to dosage.

November 18, 2017, 8:02 PM · I have always been a nervous performer -- even as a 6-year old Suzuki Twinkler.

Roger and Rocky, speaking from personal experience (and not associated with a conservatory/conservatory-prep program): I received what, for the time, was pretty good training in performance, as well as routine exposure. My Suzuki program required all students to perform in the weekly group class (about a dozen kids plus at least one parent per child) at least once every two weeks, plus multiple recitals a year. I was part of a Suzuki performing group and so played in front of people constantly. After I outgrew Suzuki, I played routinely in recitals, as well as doing church and nursing home performances and whatnot.

I was taught some basic visualization, including getting weekly instruction and practice in guided imagery at a school for the arts, as a grade-schooler. As I got older, a teacher of mine who had gotten instruction from Kato Havas taught Havas's stage-fright mitigation techniques (this was many years prior to publication of her book), and I got some Alexander Technique instruction as well. And I got instruction drawn from the Inner Game of Tennis, and eventually when the Inner Game of Music was published, that also.

To some degree, all of that helped. I am a relatively mentally calm performer, especially if I am well prepared. As I got older, though, even though my mental state got better and better, the physiological effects of adrenaline got more and more pronounced. (I've also received significant first-rate professional coaching, both in a group setting and one-on-one, for public speaking, and much of that is directly applicable to violin performance -- and vice versa.)

Now, musicians increasingly get the benefits of advances in sports psychology. The aforementioned Noa Kageyama, for instance, teaches a course in performance prep at Juilliard, as well as giving workshops and doing private coaching. I'd expect that serious young players getting high-quality preparation would receive appropriate instruction in performance. (My current teacher always has a performance mindset and strongly stresses things like how to recover from mistakes when he teaches students of all ages.)

By the way, anyone interested in competition, nerves, and the science of such things might want to read Top Dog: The Science of Winning and Losing. A fun, very relevant book.

(As an aside: I'm guessing the YouTube channel matching Roman's name is his. He's quite a fine teenaged player, and a poised performer. And exceptionally fortunate to not be subject to nerves.)

Edited: November 18, 2017, 10:15 PM · "to be subject to nerves." implicitly segregates musicians into 2 groups, which is exactly the culture I was referring to. We are all subject to nerves, aren't we? How could we speak, read or write, wake up, walk, if we were not innervated?! Many teachers simply say or imply "oh, he/she is subject to nerves", meaning, there is nothing I can do about - it is a matter for a psychiatrist or psychologist. I teach scales and arpeggios... in other words, every student is left to find on his own how to deal with the pressure. The lucky ones figure out. Less lucky do not.
Extensive stage fright is a "kiss of death" for an aspiring musician, similar to what a PTSD is to an aspiring soldier / a police officer / fire-fighter or a paramedic. One find itself in a paradoxical situation - one lives to do it, but is unable to do it. For someone who builds the whole sense of self around the concept (role) of a musician, what choices are left? Some people abandon music altogether, others self-medicate by using alcohol or other drugs. Some, like Christian Ferras, commit suicide.
There is a certain stigma attached to musicians who are unable to perform at their best. And yes, people are judged as a whole, which adds insult to an injury.
This discussion, although originally about the usage of beta-blockers, is related in many ways to issues of mental health among musicians: prevention, intervention and post-vention.
Lastly, this is our own "Elephant in the room" and I welcome this discussion.
November 18, 2017, 10:07 PM · I had prodigious musical ability (not for violin, unfortunately), but struggled with disproportionate "anxiety" for lessons and performance which brought my musical potential to a screeching halt. 20-some years later, I have learned that my "anxiety" - which was never cognitive - was a symptom of a dysautonomia medical condition that causes "adrenaline dumping" with inappropriate triggers (like a phone ringing). The condition is treated with beta blockers, incidentally. I tried taking piano lessons this past summer, but it was enough stress to cause a flare-up of symptoms. I had to drop out after 4 lessons because I was unable to drive! If I were to attempt learning music more seriously, I will likely need to take a beta-blocker in addition to my usual medication. I post this because the diagnosis I have is not particularly uncommon, but is rarely diagnosed. If your body is acting out of order, get it checked over thoroughly. It might not be "all in your head."
November 18, 2017, 10:30 PM · "You prepared so well, for so long. All those years studying the violin, all those years of struggle trying to make ends meet, all leading up to this very moment, the moment where all that hard work finally pays off...

And then you lose.

How do you feel now?

Pretty bad I guess. Like I-want-to-kill-myself type of bad probably."


Taking auditions is a game of large numbers. Very few people win a job on their first audition. Losing an audition is, as Lydia said, part of the process. Learning to handle disappointment is right up there with learning to handle criticism on the path to becoming a professional musician. I don't remember now how many auditions I took in the early years of my career, but I certainly lost more than I won, and by a fair margin. And one learns pretty quickly not to make a huge deal about a single audition. Telling the world, or at least all of one's friends and family, in advance that one is taking a particular audition is almost always unwise.

Consider Musician A and Musician B. Musician A takes ten auditions over the course of two years, makes semis in seven of them, finals in three, is runner-up in one, but has not yet won a job. Musician B also takes ten auditions over the course of two years but is never advanced past the first round. At the end of two years, both are still unemployed but Musician A has every reason to believe that with continued preparation, eventually he/she will win a job. Musician B probably should either have been advised against a professional career in the first place or advised to audition for smaller orchestras, but at this point certainly should be definitely either be setting his/her sights lower (lesser orchestras) and/or exploring Plan B.

Any good teacher will advise students about the psychological preparation for performances and auditions as well as the musical preparation. And anyone hitting the audition circuit has probably done plenty of work in the psychology of performance as well. But there can be a physiological manifestation of nerves that is death to auditions or other uniquely high-stakes performances, and that's where beta blockers can be a useful tool.

"And in the same way, if you don’t want to be forever dependent on beta-blockers to just be able to play in a decent way and one that reflects your actual playing capabilities, you better learn effective techniques that can successfully replace beta-blockers."

You are completely missing the point. Lots of people who use beta blockers in extraordinarily stressful performance situations play beautifully without them under other, more normal circumstances. All beta blockers do, in my experience, is bring extraordinary stress (auditions, concerto performances--I'm with Bruce on this one as well) down to a more baseline normal stress (orchestra performances in my case, or lower-stress solo performances).

I am still waiting to hear from the anti-beta-blocker crowd about their personal experiences with professional orchestra auditions.

November 18, 2017, 10:41 PM · "I am still waiting to hear from the anti-beta-blocker crowd about their personal experiences with professional orchestra auditions."

Good point! So am I.

Edited: November 18, 2017, 11:49 PM · I actually have turned around through these dicussions and upon further consideration. Since the benefits seems to outweigh the risks when it comes to small dose of occasional use, I will give it a try to see how it works evenue though the stakes in my performances are never high, being an amateur player. It's good to have this option open to me.
Edited: November 19, 2017, 12:27 AM · I suppose that I am in the "anti-beta-blocker" crowd in the sense that I don't see the value... for me. I'll never be auditioning for a pro orchestra, but it doesn't alleviate performance anxiety. I mention already that I take beta-blockers daily and I'd add in sufficient dose that it lowers my heart rate at rest around 40. Does it make me less anxious when performing? Not the slightest bit! I suppose I don't get the placebo effect, but were are all different, so I can't speak for others. I can understand the desire for some to use beta blockers (or any other drugs) in high stake situations, but I am not personally inclined to a systematic use of drugs for non-medical reasons (though Victoria has more pot-shops than Tim Hortons... maybe I should try that for anxiety! A few pot-laced cookies would do the trick ;-), what do you think Yixi?
November 19, 2017, 8:01 AM · Are you actually comparing the use of beta blockers for performance anxiety with the use of marijuana? I give up.
November 19, 2017, 8:29 AM · Roger, do you not find that beta blockers alleviate the physical symptoms of adrenaline -- and for that matter, a lot of emotions in general?

When I was on a normal prescription dose of beta blockers, I found that there was a strange detachment effect in which I could mentally feel an emotion just like I normally would, but there would be no answering bodily feeling -- no increase in heart rate, or sweating, or anything like that. I could be mentally distressed but my body felt calm.

I wasn't performing at the time, but I am pretty confident that beta blockers would have completely dealt with the physical symptoms. Anxiety would still have something of an impact -- mental focus during performance is always a challenge, for instance -- but that for me doesn't have anywhere near the same impact.

November 19, 2017, 9:00 AM · "It’s sad to see the music business has become so sportive. People forget why they are playing music.
What bothers me more than using beta-blockers to remove performance anxiety in an audition, is the after-effect or losing an audition, especially a high stake one where there were lots of expectations as to the result"

It's not "sportive." It's real life. The world is competitive and the standards are very high. Those who are on the audition circuit as I was aren't playing some kind of game--they really want to play music and make a living. So yes, conservatory-trained musicians have expectations. There's nothing wrong with expectations, especially when one is trying desperately to escape that first job in lower-tier orchestras: low pay, egotistical and mediocre conductors, board members who don't even like music, poor venues, etc.

The fact that someone would dismiss these makes me wonder what that person's actual professional experiences were.

You can't just "visualize" or be talked out of nervousness. Perhaps those who claim such nonsense aren't that nervous to begin with. Or don't perform. You can gain experience from auditioning..or poor audition experience can even cause one to learn to be MORE nervous, especially if a passage went poorly.
It's an unpredictable thing.

November 19, 2017, 10:37 AM · Roger, I don't know what to think about your comment on pot. You are joking, right?
Edited: November 19, 2017, 10:09 PM · Yixi, indeed tong and cheeks comment :-) ... I should have gone trick or treating in James Bay perhaps ;-) Pop a couple gummies before performance and you're all set to go!
November 19, 2017, 10:47 AM · Lydia asked: "do you not find that beta blockers alleviate the physical symptoms of adrenaline -- and for that matter, a lot of emotions in general?"

Not in my case, but it doesn't mean it wouldn't for others.

Edited: November 19, 2017, 11:41 AM · Mary Ellen, I am not supporting the use of marijuana in all but the accepted medical uses, but for the sake of the argument, if the generally supported idea is that it is OK to use prescription drugs to alleviate performance anxiety, then there really is no moral difference between using beta-blocker and medical marijuana. The recreational use of the drug is being legalized in Canada (and is already legal for medical use, hence the numerous pot shops in Victoria), and is also legal in WA State and perhaps others, and arguably has no more side effects than beta-blockers and is (according to PTSD sufferers) effective in dealing with anxiety, so the leap from using beta-blockers to marijuana once you accept the idea of dealing with performance anxiety through the use of drug isn't all that significant. Beside, you can't tell me that no young aspiring musicians using marijuana.
November 19, 2017, 12:40 PM · Back in my childhood, teenaged students in a particular extremely competitive studio (I won't give names here) were sometimes asked to take a very small dose of Valium prior to competitions, in order to deal with performance nerves.

In the days before beta blockers, many musicians self-medicated with alcohol.

November 19, 2017, 1:29 PM · I don't think the issues being discussed are as mutually exclusive as the opposing views are making it out to be.

On the one hand mental training is absolutely a necessary and positive aspect of performance training.

Here's the book Hannigan mentions in the video:
Mindset: Awareness in Sport

On the other, each performer must do what it takes for them to deliver their performance... or do something else. The war on drugs and the general attitude towards substance abuse is based on false information. Dependence develops for about 10-15% of the population and has more to do with an addictive personality than being lured into it through gateway drugs. So as with all things in life, "know thyself" and go from there.

November 19, 2017, 3:03 PM · My turn-- I never used beta-blockers. Maybe I should have. I "lost" all my pro-level auditions do to a lack of focus and clumsiness. I suspect that Scott and the M.D. are right, it's not dangerous for those occassional extreme situations. What has not been emphasized is that part of the problem is our sub-culture of classical music--what I would call "toxic perfectionism". Nerves are much less a problem in non-classical genres.
My personal stage fright levels are;
Zero-none: Orchestra section or any non-classical performance, even when doing an amplified solo in front of a large audience.
Some nerves, tolerable; Concertmaster job, or second violin or viola for chamber music. I pretend the audience is listening to the first violin.
High, counter-productive anxiety: Audition, contest, or stand-up solo.
What is really weird is that I have less of a problem doing vocal auditions.
I have spent most of playing time, and made the most money, as a Mariachi violinist (!), it's a different world. We leave the cases in the car, tune in the parking lot, and vocal warm-up is a shot of tequila. ~jq
November 19, 2017, 3:16 PM · "Beside, you can't tell me that no young aspiring musicians using marijuana"

Of course not, but not before an audition. Marijuana is not in any way performance-enhancing. Any beneficial effect it may have on anxiety is more than likely canceled out by its other effects (disclaimer: I never tried it so this is based on what others have told me).

Beta blockers address the physiological manifestations of nervousness, i.e. adrenaline. They have no mind-altering effect at all. It's certainly possible to still feel nervous after taking a beta blocker. It's just that the uncontrollable shaking is gone.

This is just getting silly.

November 19, 2017, 4:10 PM · Mary Ellen. Bravo! I am saying this as a professional teacher like you, not like some of the amateurs who have no idea about doing orchestra or other professional auditions.
November 19, 2017, 6:26 PM · I can't imagine performing under the influence of marijuana. Would be a disaster!

Beta blockers detach your feelings from the bodily response. They do not enhance your performance in any way; they just get rid of shaky bow, sweaty hands, etc.

Scott Cole, I actually have found visualisation to be quite effective, but only to a certain extent. It does work for low-pressure situations like lessons with a new teacher, or rehearsals.

November 19, 2017, 6:52 PM · Frieda, the answer is indeed yes, teenagers (as young as 13) took Valium, and their parents were okay with it. It helped some teens, but not all, and working out the correct dosage was a trick in itself, since Valium can impact coordination.
Edited: November 19, 2017, 7:16 PM · The way I see it, beta blockers level the playing field. They may allow you to present what you've prepared. It's not as if they allow you to prepare less than others and still have an advantage, as is the case with performance enhancing drugs in sport (I guess in sport drugs allow you to recover quicker and therefore work harder, so not a precise analogy. Other drugs just make you stronger than would be possible without them. Beta blockers merely reduce the flight response. They don't enhance mental acuity, improve intonation or rhythmic accuracy. They don't increase strength or stamina. They don't enable you to play faster or cleaner. They don't enhance anything to do with violin performance.)
Edited: November 19, 2017, 7:23 PM · I too experienced the detached feeling Gabbi describes and disliked it. I never took them long enough to find an optimal dosage, but for me the first time I took about half a pill I felt there was some benefit (and I visualized each excerpt repeatedly, driving to the audition,) in terms of being able to keep nerves, and related physical responses, in check. But the second time I felt no benefit.
Edited: November 19, 2017, 7:30 PM · "beta blockers level the playing field" that's one way of rationalizing it in one's mind. Similar to "cheating on your taxes is only fair since the government is stealing from you" kind of reasoning! But I agree, it won't make you more skilled than what you are, it only takes away one weakness (for those for which it works), performance anxiety, which makes you look is if you can (but really can't otherwise) perform as well as and hopefully better than those who don't take the drug. But this isn't performance enhancing? It enhances your ability to perform under stress no? Not sure what the Olympic committee would think of it. Whenever you are tempering with your metabolism to perform better, it is by definition performance enhancing.
Edited: November 19, 2017, 7:37 PM · But the only measure in the arts is the experience of the audience, the communication between performer and audience. If a performer disturbs the performance due to an above normal adrenaline response, does that not cheat the audience of their experience? In taxes and sport their is a different measure of what is fair. When it comes to competition, if you don't bring your physical response to a similar level as everyone else aren't you just cheating yourself?

"Weakness" is a judgment, along the lines of shoulder rest use, which only the privileged make. If you allow your physiological response to dictate your performance are you not choosing to remain weak, relative to others with a similar playing capability?

Edited: November 19, 2017, 8:05 PM · "When it comes to competition, if you don't bring your physical response to a similar level as everyone else aren't you just cheating yourself?" ... and that's how performance enhancing drugs become prevalent in competitive sport! I see a general acceptance of using "drugs" for performance enhancing, leveling or whatever you'd like to call it, and somewhere in the grey zone it reaches a level that is no longer considered acceptable. What if music competitions were excluding drugs as it is for sport competitions (albeit with mix success), would beta-blockers be considered acceptable? Apparently the relative benign nature of beta-blockers makes it "acceptable". Psychotic drugs, makes some of us uncomfortable, but what if I take Benzodiazepines such as Valium (diazepam), Xanax (alprazolam), Klonopin (clonazepam) and Ativan (lorazepa), which are sometimes used to treat anxiety for a short-term period?
Edited: November 19, 2017, 7:51 PM · All rules are arbitrary (morality has to do with harm done to others, not genetic advantage.) There are no comparable rules in the arts, no rules against compensating for genetic disadvantage. In sport there are no rules against financial and cultural advantage.

Edit: what is sport but the celebration of hard work and genetic fitness? The arts celebrate hard work and human expression.

November 19, 2017, 7:47 PM · Beta Blockers is the new shoulder rest Shaking hands and grace long necks need crutches. It's certainly not doping in sports.
Edited: November 19, 2017, 7:50 PM · Roger, the government/tax analogy is not accurate here.

Frieda, that is not enhancing, it's levelling. Most people do not experience nerves to the point where they need drugs; so if someone does, they are in a more difficult position than their peers, thus the need for beta blockers to even things out. Due to the nature of beta blockers, it is impossible for them to actually improve someone's playing ability.

Performance *enhancing* drugs would do things like sharpen the mind, increase motor skills, or otherwise put you in a position you could not reach without the drugs. As people have explained many times, beta blockers literally just take away the physical symptoms of excessive anxiety. It's like saying a student with depression who took an antidepressant before an English exam is using it to enhance their performance - no, they are putting themself on the same playing field as the rest of the class.

Edited: November 19, 2017, 7:58 PM · As Yixi implies, it's a weird thing to automatically paint crutches in a pejorative light. Crutches enable people to do things other people take for granted, which they'd otherwise be unable to do. It becomes a negative only when they continue to be used after they become unnecessary.
November 19, 2017, 7:59 PM · Ironically the people mentioning crutches are proving our point that beta blockers are a leveller rather than an unfair advantage.
Edited: November 19, 2017, 8:04 PM · I see the point, and acknowledge that I can't win the argument, but if I were assessing two competitors who play equally well, one with and the other without the help of drug, I'd hire the one without. I suppose that's discrimination!

November 19, 2017, 8:11 PM · Switching to the other extreme end of the spectrum: I know a number of amateurs for whom beta blockers have made performing a fun experience, rather than a stressful one. Some of them have received serious enough training that they are mentally calm performers. Others are still pretty nervous even with the beta blockers, but the beta blockers eliminate the physical issues fairly well. I'm generally supportive of their use, too, especially since for most amateurs, high-stakes performances are pretty rare.
November 19, 2017, 8:18 PM · Lydia, I think that is pretty much the general consensus.
November 19, 2017, 8:30 PM · That is discrimination based on mental health.
November 19, 2017, 8:47 PM · I don't think the conditions of a solo career are all that close to competition conditions. Competitions and auditions are unnaturally stressful events in which a single slip can be disastrous, and there is ultimately only one winner. Even when there is an audience at a competition, the candidates are well aware that they are playing for the judges who will catch and care about the tiniest flaw. The focus is on winning, on being *the best.*

Solo performances are for the benefit of an audience who are typically predisposed to be friendly. One small slip in a live performance is not going to blacklist a soloist. The focus is on playing music and sharing one's art with an audience.

Apples and oranges. Or perhaps apples and lemons might be a more apt comparison.

November 19, 2017, 9:22 PM · I really can't even believe this is a debate. Beta blockers aren't heroine. Use them if you need them, or if they help you. Period (minus health contraindications).

If you don't need them, or they don't help you, don't use them.

November 19, 2017, 9:53 PM · Context is everything. What a society values is arbitrary.

November 19, 2017, 10:11 PM · Thank you for that excellent article, Jeewon.
November 19, 2017, 10:14 PM · My guess is that daily use of beta blockers (i.e., the situation of a performer who needs them to function in their full-time orchestra job) would lead to an acclimatization effect that would ultimately make them less effective.

I wonder if that's the reason that Roger doesn't find that his beta blockers help his performance, for instance -- his body is used to them.

Edited: November 20, 2017, 9:55 AM · Lydia, that is certainly a possibility, or perhaps the dose is insufficient. I think the article pointed above mentioned taking 10mg, which would be extreme for me. I was on 5mg daily, and that caused almost nightly leg cramps. I found myself one night waking up with both legs hard as wood in excruciating pain. Sat up trying to get blood flow going, which along with the pain caused my blood pressure to drop, and as the beta blocker prevented my heart to compensate with a faster beat, led to insufficient blood flow to the brain and I started to loose motor functions almost passing out and ended up in an ambulance. So needless to say that I won't be popping in 10mg just to play a concert. Even with as little as 2.5mg a day, my heart beat is down to 40. Pills aren't without consequences, even when you think there aren't any side effect for you. Obviously taking the occasional pill doesn't nearly have the same consequences, but one need be aware that there are always risks in messing around with our own biochemistry. Take a little too much at the wrong time and you could find yourself passing out in the middle of your audition.
November 20, 2017, 9:55 AM · Almost any drug can wreak havoc on people so a close consultation with the physician is crucial. Even ordinary OTC drugs such as NSAIDs can increase the risk of heart attack or stroke. Besides, I don't think the musicians who support beta blockers are pill-poppers at all.
November 20, 2017, 10:05 AM · I don't think we can generalize as such, but it is easy to develop a casual attitude toward popping pills when all we discuss is the positive effects, and no perceived consequence.
November 20, 2017, 11:51 AM · Dear all,

First of all, thank you for responding to my questions in such an elaborate way, and for the interesting discussion that came out. I was hoping to find different opinions and perspectives, and that is exactly what happened!
I am still curious to know whether any of the beta blocker-users among you have experienced any (bad) side-effects; for example, did you ever feel like you were not as concentrated as you could have been, or 'less engaged' in the music while playing?

Edited: November 20, 2017, 11:54 AM · Oh good grief. I don't know any musician who is a casual "pill popper." I acquired my prescription beta blockers from a physician with whom I discussed the proper dosage. I then experimented with other performance situations before the actual audition to make sure that I was not taking too much or too little. Everyone that I was aware of who was using beta blockers for auditions was taking pretty much the same approach.

People who are trying to get a highly skilled job in a competitive market tend to be responsible people.

Edited: November 20, 2017, 11:54 AM · "I am still curious to know whether any of the beta blocker-users among you have experienced any (bad) side-effects; for example, did you ever feel like you were not as concentrated as you could have been, or 'less engaged' in the music while playing?"

No, that never happened with me. I was more engaged with the music because I was not distracted by distressing physical symptoms.

November 20, 2017, 12:49 PM · If I am short-sighted I wear glasses; if I am diabetic I take insulin; if I have attention disorder I may benifit from Ritaline....

I have none of these problems, but I have seen the benefits of all three treatments.

It seems that other folk's problems are always their own fault.

November 20, 2017, 2:20 PM · Haha, Adrian it's like saying "stop making excuses, you're using those glasses as a crutch! Use yoga and mindfulness instead!"

To answer your question OP, I haven't experienced side effects since the very first time I used beta blockers, and even then it was just a lot of drowsiness/a sort of drunk feeling.

Edited: November 20, 2017, 3:25 PM · The side effects and interactions of beta blockers are clearly indicated in literature provided by the dispensing pharmacy and on line. Some people will have some of these interactions and some wiil not.
I have some of them.

One of my most interesting uses of Inderal (the first Rx beta blocker I took) occurred back in the early 1980s when we were going to perform the Brahms Horn Trio. The pianist and horn player saw me ready to take it and we decided to split the pill in thirds, because the horn player said he had trouble getting enough "wind" in solo situations and the pianist (who had worked his way through college playing piano) said also tended to get over stimulated. It went really, really well - I think we all felt we could totally depend on each other.

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