Beta Blockers and Performance Anxiety
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some blogs on this website about this particular subject, but most of them are several years old, and could be a bit outdated.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?
You mean, like, performance enhancing drugs? :-)
You will probably get more and better responses if you give people a way to respond to you privately.
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 have the same opinion as Jim
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.
You can probably find everything I written on line about beta blockers/performance anxiety/essential tremor by googling "beta blockers Andrew Victor"
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!
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.
Agree with Gene 100%.
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....
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.
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.
Try reading "Sticking It Out," by Patti Niemi, memoir of a professional symphony percussionist whose entire professional career has depended on beta blockers.
Well I can’t really say anything because I never had any serious nervousness issues.
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.
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.
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.
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.
Lol, I feel for Gemma, she’s new on this forum, and the poor girl is getting sacked left and right :D
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.
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.
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.
Holy projection, David!
Christian, can't rule that out. But in my admittedly limited experience, medications have seldom been the best substitute for addressing underlying problems.
This post is a survey, and I was simply answering the questions. I did not ask for advice.
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.
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 would add "being too self-critical" to that list, but that's a good point.
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.
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.
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.
Thank you for explaining that.
According to Mayo Clinic (https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/beta-blockers/art-20044522?pg=2):
"Anxiety is not a product of teenage immaturity, it is a debilitating medical condition..."
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.
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.
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.
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.
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.
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, https://youtu.be/4zSzX82LsTo?t=768.
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.
Glenn, thank you for the insight into the process and much needed words of wisdom.
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.
"Beta blackens are not anti-anxiety medications or antidepressants, they don’t work in the brain..."
I shall point out that this was his instrument exam, it’s a music university.
Do you know what the number 1 fear people have is?
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.
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.
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.
I agree 100% with Scott.
Lydia, first let me say that I am not arguing against taking beta-blockers if other equally good alternatives are not currently available.
Scott and Lydia have explained the nature of a professional orchestra audition thoroughly and accurately.
Roman, I mean this in the least demeaning way possible: what is your experience with musical auditions and/or the professional music world?
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?
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.
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.
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.
Well we are now entering the bigger question of how highly competitive environments can have destructive effects on those who evolve within it.
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."
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.
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.
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?
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).
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.
The main question remains unanswered though:
Sorry, I’m having trouble with my browser posting my response prematurely.
I have always been a nervous performer -- even as a 6-year old Suzuki Twinkler.
"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.
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."
"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...
"I am still waiting to hear from the anti-beta-blocker crowd about their personal experiences with professional orchestra auditions."
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.
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?
Are you actually comparing the use of beta blockers for performance anxiety with the use of marijuana? I give up.
Roger, do you not find that beta blockers alleviate the physical symptoms of adrenaline -- and for that matter, a lot of emotions in general?
"It’s sad to see the music business has become so sportive. People forget why they are playing music.
Roger, I don't know what to think about your comment on pot. You are joking, right?
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!
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?"
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.
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.
I don't think the issues being discussed are as mutually exclusive as the opposing views are making it out to be.
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.
"Beside, you can't tell me that no young aspiring musicians using marijuana"
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.
I can't imagine performing under the influence of marijuana. Would be a disaster!
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.
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.)
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.
"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.
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?
"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?
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.
Beta Blockers is the new shoulder rest Shaking hands and grace long necks need crutches. It's certainly not doping in sports.
Roger, the government/tax analogy is not accurate here.
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.
Ironically the people mentioning crutches are proving our point that beta blockers are a leveller rather than an unfair advantage.
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!
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.
Lydia, I think that is pretty much the general consensus.
That is discrimination based on mental health.
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.*
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).
Context is everything. What a society values is arbitrary.
Thank you for that excellent article, Jeewon.
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.
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.
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.
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.
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.
"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?"
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....
Haha, Adrian it's like saying "stop making excuses, you're using those glasses as a crutch! Use yoga and mindfulness instead!"
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.
This discussion has been archived and is no longer accepting responses.