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Beta Blockers and Social Phobia
Suzy takes a deep breath. Hands trembling, heart pounding, lips quivering and mind racing; she knows that tonight is the biggest night of her life. Countless hours spent practicing, honing her skills, and this, this is the moment where she must lay it all out. Minutes before she is set to go on stage, to play piano in front of a stage of hundreds, including several prominent critics from her local newspapers, Suzy reaches in her purse for her secret weapon; a tiny blue pill purported to assuage all her fears. This pill is propranolol, a pharmaceutical in the line of drugs called beta-adrenergic blocking agents. Beta-adrenergic blocking agents, or beta blockers, have been called the “musician’s underground drug” due to the widespread abuse of such medicines to treat performance anxiety in musical performers (http://www.ethanwiner.com/BetaBlox.html). However, this use of the drugs is not limited to musicians in any way, as these days more and more individuals use beta blockers for the purpose of alleviating social phobia and anxiety. Often times the ability of beta blockers in this form comes from mere hearsay and word of mouth that travels within social circles. Not until relatively recent times has scientific inquiry been used to analyze the true effects of beta blockers on social phobia. In this literature review I will aim to discuss the history and physiological effects of beta blockers, examine their use for the purpose of treating social phobia (with specific attention given to social phobia in stage performances, or stage fright), and consider the research on the efficacy of the class of drugs in this manner.
Beta blockers have long been viewed as miracle drugs in the realm of cardiovascular medicine due to their ability to block the effects of the hormone epinephrine, or adrenaline. In the early 1960’s Sir James Black revolutionized the medical world by inventing the first successful beta blocker, propranolol. The historical basis of beta blockers, however, far precedes Sir James Black’s discovery, and begins with the first chronicled depiction of angina pectoris in 1768. “They who are afflicted with it are seized while they are walking”, the description read, “with a painful and most disagreeable sensation in the breast which seems as if it would extinguish life…” (Stapleton, 1997). Although the portrayal was well narrated, the physiological roots and causes of angina pectoris would not be known for nearly two hundred years. The first big breakthrough in the investigation came in 1948 from Raymond Ahlquist who determined that two different receptors, called alpha and beta receptors, were what caused certain tissue responses. This work heavily influenced Sir James Black, who, while others were looking for a way to increase mydocardial oxygen delivery to prevent angina pectoris, viewed the dilemma from another angle; could the mydocardial need for oxygen be reduced? From the discovery of dichloroisoprenaline, the first actual, yet clinically useless beta blocker, came pronethalol, and eventually the first clinically viable beta blocker, Imperial Chemical Industries’ compound ICI 45,520, or propranolol. Evidence after evidence surged in, showing that propranolol “reduced both morbidity and mortality in angina sufferers”, and in 1967 propranolol was released to the market under the trade name Inderal. Sir James Black’s discovery was quickly heralded as a milestone moment for cardiac medicine of all kinds, and propranolol and other subsequent beta blockers were soon being used to treat a myriad of conditions, such as hypertension, cardiac arrhythmias, and post heart attack cardiac management (Stapleton, 1997).
Physiological Effects and Prevalence of Abuse:
Because beta blockers mute the effects of epinephrine, they have become immensely popular with those trying to treat social phobia, particularly musicians. Social phobia, also known as social anxiety disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as, “A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others” (http://www.socialanxietyinstitute.org/dsm.html). When one is in such a situation, epinephrine is produced in high quantities in the body, and this prompts the “fight or flight response” which physiologically entails, among other things, the acceleration of the heart, shaking throughout the body, and inhibition of stomach actions. Beta blockers, which curb the effects of epinephrine, and therefore dull the fight or flight response, are therefore found to be useful in controlling social anxiety. This works both by direct action, and by stopping a “feedback loop” in which an individual’s anxiety is increased due to the awareness of their physiological response to the anxiety (Taggart, 1976). Since the Food and Drug Administration (FDA) has never approved beta blockers for treating anxiety, this use is considered “off-label”. Musicians were the first to begin using beta blockers in this “off-label” manner, being regularly exposed to intense performance situations which brought about anxiety. This usage among musicians was first identified in 1976, and by 1987, a survey by the International Conference of Symphony Orchestra Musicians, exposed that 27 percent of the musicians in the 51 largest orchestras in the United States had used beta blockers for performance anxiety related issues (Tindall, 2004).This number has undoubtedly risen since that time. Although physicians normally do not hesitate prescribing beta blockers for this reason, due to their relative safety in relation to other methods of taming social anxiety such as benzodiazepines and alcohol, the same 1987 survey found that 70 percent of those who said they took beta blockers admitted that they received them from friends, rather than doctors. This creates problems in certain individuals who have asthma or some heart related issues or take medications which could react dangerously with the beta blockers. Additionally, the use of these drugs is many times kept hidden even within the circles due to ethical concerns likening performing on beta blockers to using performance enhancing steroids in sporting events. Some are even considering regular drug testing for concert musicians and those who audition for parts (Slomka, 1992).
While beta blockers remain a popular drug for occupations that require relatively short, intense performances, such as musicians and comedians, their prescription and use for social anxiety in the general public remains rare. Some websites online that target those afflicted with social anxiety discuss the use of beta blockers, and the thinking behind the claims. These websites generally echo the data that beta blockers are used prominently in music circles, and then go on to examine the treatment capability of these medicines for those suffering from daily social anxiety. Surprisingly, most of the information that I found online was accurate and would be helpful to those with social anxiety. All of the websites that I looked at stressed that self medication was not wise and that beta blockers, while helpful in some respects at treating anxiety, were not FDA approved for this use (http://controllinganxietyattacks.com/beta-blocker-anxiety-help, http://www.socialanxietyassist.com.au/treatment/medication.shtml). These websites many times cited reputable sources, such as the ones I have been using throughout the paper, to provide evidence for their claims. Delving deeper for information about the websites themselves I found that they were many times sites belonging to small, local or online-only, groups for those afflicted with social anxiety. Their main motives were simply to help others. Because beta blockers are legitimate medications with little potential for serious abuse, there is no market for illegal sale (as with medications, such as opiate painkillers, that are regularly abused) or duping of unsuspecting customers (as with herbal supplements that are promised to deliver the world). It seems that in this case, the internet was truly a help.
Although beta blockers are no doubt used regularly by many to treat the symptoms of social anxiety, their efficacy in this context has been put to question. The first clinical trial to determine the effectiveness of beta blockers for social anxiety sought to directly identify their effects on musical performance. In 1970, Charles Brantigan reproduced anxiety-inducing playing conditions and measured blood pressure, heart rate, and “musical performance as judged by experts” in the performers. His research found that blood pressure and heart rate both decreased and musical performance was judged superior in those using propranolol versus those given a placebo. In 1982, another study, published in the Psychosomatic Medicine Journal, looked at the same question. Participants in this study, string players, were given either 100 mg of atenolol or placebo 6.5 hours before performing. The study measured heart rate, self reported stage fright (both before and after the performance), and technical-motor performance as judged by “increase in the relative variance of repeated fast elements of movements”. The participants in the atenolol group had significantly lower heart rates, and post performance stage fright reportings, but were unaffected in their pre-performance stage fright reportings. Additionally, sonographic data showed that, in the atenolol group, technical-motor performance in the fast element movements showed much less variability, meaning that the beta blockers allowed the participants to play difficult portions of the music much more accurately (Neftel et al., 1982). Other similar but non musical-performance related studies have also shown increases in performance in anxiety enabling situations. In a study published in the British Journal of Psychiatry, subjects were given either 40 milligrams of propranolol or a placebo and were required to give a brief speech that was videotaped. The videotape was then reviewed by trained specialists for signs of anxiety and the subjects were asked to self report their anxiety during the speech. The participants in the propranolol group were determined to show less non-verbal and verbal signs of anxiety than the control group. Additionally, propranolol affected self-reported anxiety, with the treatment group reporting to be significantly less anxious while delivering the speech (Hartley et al., 1983). While beta blockers have been shown to produce positive results in dealing with social anxiety in specific, high intense performance situations, the literature has shown less than favorable results for individuals with social anxiety in normal day to day situations. In a 1980 study published in the Archives of General Psychiatry, subjects with chronic social anxiety disorder were asked to cease taking their prescribed anti-anxiety medications, and after an initial “washout” period to measure baseline non-medicated anxiety, were given either propranolol in 40 milligram doses or a placebo. Anxiety was measured weekly using the Hamilton Anxiety Scale and a secondary scale measuring severity of the symptoms. While participants in the test group showed improvement over baseline anxiety, the results of the study suggested that other forms of anti-anxiety medication were more effective (Kathol et al., 1980). Further literature supports this position (Hayes & Schulz, 1987).
Multiple studies demonstrate that beta blockers are beneficial in quelling the physiological effects of social anxiety; however this does not necessarily presuppose that these drugs are having any true effect on the cognitive aspects of the anxiety. Although one study showed that self reported stage fright after a performance was deemed lower when on atenolol than on placebo, this could be a byproduct of increased post-performance confidence which comes from the effects of atenolol on technical ability, rather than a true decrease of stage fright and anxiety during the performance. The finding that pre-performance stage fright is completely unaffected by atenolol seems to back this assumption. Similarly, lower post-performance self reported anxiety in a study where participants had to give speeches could be explained again by the confidence gained after-the-fact by increased verbal performance (less mistakes made during the speech), rather than decreased cognitive anxiety during the speech. Until a study is designed where subjects can actively self report anxiety during a performance, these questions remain unanswered.
Another important factor to consider when discussing the benefits of beta blockers for musicians is the question of what defines the quality of a piece of music. Although it has been shown that beta blockers increase technical accuracy in performances, many times these technical faults give the music personality and “feeling” (Neftel et al., 1982). Some of the greatest musicians of all time, most notably legendary guitarist Jimmy Hendrix, have been heralded for the intensity and emotion that they bring to their music and performances, not their technical abilities. Many experts claim that the personal passion of music is gone when performed on beta blockers (http://www.nytimes.com/2004/10/17/arts/music/17tind.html).
Summary and Conclusions:
Beta blockers, while initially developed to aid in treatment of cardiovascular diseases and health issues, have been historically used to treat anxiety. By taming the effects of the hormone epinephrine, beta blockers also mute the physiological symptoms that come with increased epinephrine, such as increase in heartbeat, sweating, and trembling. Musicians, due to their routine susceptibility to high anxiety related events have been known to use these drugs for their alternative effects. The results suggest that beta blockers do indeed have a positive impact on the physiological side effects of anxiety, yet the results do not definitively imply that the cognitive feelings associated with the anxiety are blocked. Additionally, because of the nature of how the drug is commonly used, most of the literature is focused on people who do not have chronic social anxiety disorder but occasionally put themselves in situations of high anxiety. Those studies that have viewed the drug as a replacement for typical anti-anxiety medication have not seen substantial effectiveness. Beta blockers, while viable in treating the symptoms of social phobia for those who sometimes find themselves in high anxiety situations, cannot be recommended as an alternative for current leading social anxiety medications in patients with chronic social anxiety disorder.
Harby., K., Kucharski., K., Tuck., S., & Vasquez., J. (1997). Beta blockers and performance anxiety in musicians. Retrieved from http://www.ethanwiner.com/BetaBlox.html
Hartley, L.R., Ungapen, S., Davie, I., & Spencer, D.J. (1983). The effect of beta adrenergic blocking drugs on speakers' performance and memory. British Journal of Psychiatry, (142).
Hayes, P.E., & Schulz S.C. (1987). beta-blockers in anxiety disorders. Journal of Affective Disorders, (13).
Kathol, R.G., Noyes, R., Slymen, D.J., Crowe, R.R., & Clancy, J. (1980). Propranolol in chronic anxiety disorders. Archives of General Psychiatry, (37).
Neftel, K.A., Adler, R.H., Kappeli, L., Rossi, M., & Dolder, M. (1982). Stage fright in musicians: A model illustrating the effect of beta blockers. Psychosomatic Medicine, 44(5).
Richards, T.A. (1996). DSM-IV definition: Social anxiety disorder. Retrieved from http://www.socialanxietyinstitute.org/dsm.html
Slomka, J (1992). Playing with propranolol. The Hastings Center Report, 22. Retrieved from
Stapleton., MP. (1997). Sir James Black and propranolol. The role of the basic sciences in the history of cardiovascular pharmacology. Texas Heart Institute Journal, 24(4).
Taggart, P (1976). Editorial: Beta-blockers in anxiety and stress. British Medical Journal, 1(6007).
Tindall, B (2004, October 17). Better playing through chemistry . The New York Times. Retrieved from http://www.nytimes.com/2004/10/17/arts/music/17tind.html
All pictures obtained via Microsoft Office 2007 Clip Art or Wikimedia Commons, a free resource for unlicensed images (http://commons.wikimedia.org/wiki/Main_Page).
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