Psychology Department

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Papers written by students providing scientific reviews of topics related to health and well being

Date: 11/15/2005

Beta blockers, a class of prescription drugs traditionally used to treat hypertension and heart conditions, have recently gained popularity as the “musician’s underground drug” (http://www.ethanwiner.com/BetaBlox.html). Beta blockers fit chemically into beta receptors present in the heart, lungs, arteries, brain, and uterus. By diminishing the effects of adrenalin e, the hormone that increases heart rate in times of anxiety, beta blockers slow the nerve impulses traveling to the heart. This reduces the work of the heart, because the amount of blood and oxygen it requires is minimized. The peak effect of beta blockers generally occurs one to two hours after the dose is administered. The approved uses of beta blockers include treatment for heart attacks, heart failure, high blood pressure, abnormal heart rhythms, migraine headaches, and tremor. The FDA has never approved the usage of beta blockers for stage anxiety or fright (http://www.findarticles.com/p/articles/mi_m1175/is_5_36/ai_n6015160).

The history of using beta blockers as treatment for stage fright is somewhat obscure. In the late 1970's, Charles Brantigan, a surgeon, began researching the use of beta blockers by musicians. He replicated performance conditions for musical students, measuring their pulse (heart rate), blood pressure, and musical performance as judged by experts. His studies showed that all three test conditions were improved by the use of beta blockers as compared to placebo. Since then, multitudes of musicians have used the drugs surreptitiously to calm their nerves during important performances. Not until recent years has this fact been made public, and the response to this use of the drugs has been mixed.

Some medical professions fully support the use of beta blockers for anxiety. "Stage fright is a very specific and time-limited type of problem…there's very little downside except whatever number you do on yourself about taking the drugs,” states Michael Craig Miller, editor of the Harvard Medical Letter. Often musicians use alcohol or Valium prior to performances, and beta blockers are seen as a safer alternative. (http://www.mozartinthejungle.com/work4.htm). Social worker Diane Nichols, who specializes in helping musicians manage stage fright, is quite casual about the use of beta blockers. She claims that they are simply “kind of like breath mints.” Some journalists also deem beta blockers as a useful treatment for stage fright. The New York Times featured an article in 2004 praising the drugs’ effects as “magical,” inexpensive, and relatively safe.

Musicians’ praise of beta blockers for managing performance anxiety appears widespread. Some claim that beta blockers allow musicians to perform at their best without the problems resulting from the fight or flight response, a common term describing the effects of increased adrenaline on the system. (http://www.ethanwiner.com/BetaBlox.html) Other musicians agree that drugs act as the only cure for dealing with high pressure situations. (http://www.journalism.ubc.ca/thunderbird/2005.03/features/betablockers.html) In a recent survey, 22% of musicians reported using beta blockers for stage fright, with 70% of those acquiring the medication without a prescription.

Certainly, dangers arise from the use of a prescription medication without a doctor’s supervision. The documented side effects of beta blockers make many physicians uncomfortable with their casual use. Potential side effects include dizziness, drowsiness, hallucinations, nightmares, depression, and other central nervous system problems. Beta blockers are very rarely prescribed to asthma patients, since they can hinder breathing. Additionally, without adrenaline as the body’s natural defense, allergic reactions can quickly progress to shock and death. (http://www.journalism.ubc.ca/thunderbird/2005.03/features/betablockers.html) Despite these vital medical concerns, beta blockers continue to be praised on websites as a safe miracle medicine for performance anxiety. They are advertised on the internet as a treatment to “quell anxiety without apparent side effects” (http://www.mozartinthejungle.com/work4.htm). This claim is absolutely untrue; the side effects are numerous and potentially serious. In fact, the side effects may be more severe when the medication is taken intermittently, as is often the case with musicians using drugs for stage fright.

What alternate treatments are available for stage fright and performance anxiety? Numerous options including biofeedback, yoga, relaxation, cardiovascular fitness, cognitive therapy, and diet changes have been shown to have some effect on stage anxiety (http://www.ethanwiner.com/BetaBlox.html). Websites, however, refute these holistic treatments as slow and uncertain when compared to medication: “(They) take work and time to be effective, whereas Inderal (a beta blocker) is a quick fix,” according to Robert Barns, co-chairman of music performance studies at Northwestern University.

An argument by the opponents of the use of beta blockers for stage fright compares this “underground drug” to the use of steroids in sports. If steroids are deemed inappropriate for athletes, they reason, why should competitive musicians be permitted to use performance-enhancing drugs? In fact, the World Anti-Doping Agency prohibits the use of beta blockers for athletes. In the past, athletes have used beta blockers because they steady the hands. (http://www.journalism.ubc.ca/thunderbird/2005.03/features/betablockers.html) Their use was especially prevalent at one point in riflery and archery, since they slow the heart rate, allowing shots to be made between heartbeats. If this exact drug class is outlawed in athletics, it seems reasonable that beta blockers should also be prohibited in musical performance. Musicians are quick to oppose this view. According to many people, the nature of sports is fundamentally different than that of music. (http://www.beggingtodiffer.com/mt/mt-comments.cgi?entry_id=2171) Proponents claim that musicians are known for “sex, drugs, and rock & roll,” not the fierce competition of athletes. Additionally, musicians are not considered to be role models for children and teenagers like sports stars. These differences, people claim, make the comparison between illegal drug use in athletes and musicians null. They insist that discussions of ethics in artistic performance are unnecessary, since art is produced by a combination of psychology, emotion, and physicality. Steroids produce an artificial strength in athletes, but beta blockers allow for a truer self (http://www.juilliard.edu/update/journal/j_articles521.html). Some obvious holes exist in these arguments, however. Classical musicians don’t generally have the “sex, drugs, and rock & roll” reputation, and they are the most prevalent users of beta blockers as treatment for stage fright. Musicians may also serve as role models. Not all children are interested in athletics, so any professional should maintain ethical standards in order to set a good example for younger members of society. Finally, physical components of music play a significant role in performance. Still hands and a slow heartbeat are advantages in competitive musical performance, so the use of beta blockers could easily be deemed as performance enhancing.

Aside from the ethical issues implicit in illegal drug use by musicians, do beta blockers actually work as treatment for stage fright? Few studies have been done on this topic, and the majority of relevant research is dated.

A study published in 1991 studied the physical reactions to stage fright in musicians. Professional musicians, categorized as either high anxious or low anxious, were studied during important performances regarding their subjective anxiety, neuroendocrine signals, and cardiovascular function. Ratings of effort and stress served as the measures for subjective anxiety. Norephineprine, ephinephrine, cortisol, and heart rate increased in the high anxiety musicians during public performances (Fredrikson et. al., 1992). While beta blockers could theoretically control these physical symptoms of anxiety, do they truly work in performance situations?

One study, published in the Psychosomatic Medicine Journal in 1982, explored this precise question. The researchers administered either 100 mg of atenolol or a placebo to twenty-two performing string musicians six hours prior to their performance. The subjects’ heart rates, stage fright (as measured by a scale), technical motor performance, and urine catecholamine were measured during their concert. Interestingly, while heart rate was significantly lower in patients receiving the beta blocker, the technical motor performance (as rated by musical experts) did not improve significantly. While slight improvements in stage fright were recognized during the concerts, the beta blockers had no effect on stage fright prior to the shows (Neftel et. al., 1982). Thus, these results showed that while beta blockers decrease heart rate, they do not allow for improved musical performance or significant decrease in stage fright.

Other research opposes this, however. In a 1982 study, 29 musicians were administered propranolol (a beta blocker) or a placebo in a double blind method. The only variable measured in this study was the quality of the musical performance, as judged by music critics. According to the results, the quality of performance of the subjects using beta blockers “significantly improved” (Brantigan et. al., 1982). It seems that this subjective variable would be difficult to measure accurately and consistently. Without other measures of the effects of the beta blockers, it is difficult to give this study much credence.

A slightly different study completed on musical students, as opposed to musical professionals, gave similarly vague results. Thirty-four singing students were given 20, 40, or 80 mg of nadolol or a placebo during end of the semester juries. Musical juries in college are graded performance exams. This research showed that a low dose of beta blockers improved performance minimally, and a high dose hindered performance significantly (Gates et. al., 1985).

The research on the use of beta blockers as treatment for stage fright is lacking in depth and design. All of the studies found on the topic include small numbers of subjects, fewer than forty in all cases, which diminishes the reliability of the results. Larger numbers of subjects are much more desirable in these studies to decrease the potential for experimental error. Additionally, the validity of these studies seems questionable. With subjective ratings of musical performance used as the only measure of decrease in stage fright, several of these research designs are unclear. Was it valid to use subjective ratings of musical performance as an indicator of stage fright? Did this research accurately measure the change in stage fright by using these variables? The small number of studies, their questionable reliability, the error margin due to statistically inadequate numbers of subjects, and the unclear measurement standards mandate more research on this topic before a clear conclusion can be made.

Due to the dangers of side effects, the legal and health implications of prescription drugs obtained illegally, ethical questions related to musical performance, and a lack of significant experimental evidence supporting the treatment, the use of beta blockers to minimize stage fright in musicians is not supported at this time. The effects need to be clarified by further and more in-depth research on the question. If increased research shows beta blockers to actually serve the purpose of treating stage anxiety, a proposal of this treatment should be submitted to the FDA for consideration. In the meantime, alternative treatments ranging from cognitive therapy to exercise can provide some relief. Beta blockers should only be used to treat stage fright following the legitimate approval process for the use of a medication by the FDA and in conjunction with approval from ethical committees in major music institutes who have debated, determined, and sanctioned the use of such drugs in professional musical performance. As with any prescription drug, these medications should be used only under physician supervision.

(1) Harby, Karla et. al. “Beta Blockers and Performance Anxiety in Musicians,” http://www.ethanwiner.com/BetaBlox.html

(2) Lindsay, Bethany. “Steroids for the Symphony.” 24 March 2005.

http://www.journalism.ubc.ca/thunderbird/2005.03/features/betablockers.html

(3) Tindall, Blair. “Better Playing Through Chemistry.” 17 Oct 2004.

http://www.mozartinthejungle.com/work4.htm

(4) “Musicians Don’t Cheat.” 8-9 Dec 2004. http://www.beggingtodiffer.com/mt/mt-comments.cgi?entry_id=2171

(5) Jozefowicz, Chris. “Feelin’ Beta All the Time: Anxious White-Collar Workers Turn to Cardiac Drugs.” Sept-Oct, 2003. Psychology Today. http://www.findarticles.com/p/articles/mi_m1175/is_5_36/ai_n6015160

(6) Kwak, Paul. “Combating Stage Fright with Beta Blockers.” April 2005. The Julliard Journal Online. http://www.juilliard.edu/update/journal/j_articles521.html

(7) Neftel, KA et. al. “Stage Fright in Musicians: a Model Illustrating the Use of Beta Blockers.” Psychosomatic Medicine 44.5 (1982): 461-69.

(8) Brantigan, CO et. al. “Effect of Beta Blockade and Beta Stimulation on Stage Fright.” American Journal of Medicine 72.1 (Jan. 1982): 88-94.

(9) Gates, GA et. al. “Effect of Beta Blockade on Singing Performance.” Ann Otol Rhinol Laryngol 94.6 (Nov-Dec 1985): 570-4.

(10) Fredrikson, M et. al. “Psychobiology of Stage Fright: the Effect of Public Performance on Neuroendocrine, Cardiovascular and Subjective Reactions.” Biol. Psychology 33.1 (May 1992): 51-61.