Effect of beta blockade and beta stimulation on stage fright

Effect of Beta Blockade and Beta Stimulation on Stage Fright

C. 0. BRANTIGAN, M.D. Denver, Colorado

T. A. BRANTIGAN, D.M.A N. JOSEPH, M.D. Omaha, Nebraska

From the University of Colorado Health Sciences Center. Denver. Colorado. University of Nebraska Medical Center,’and Dundee Presbyterian Church, Omaha, Nebraska and Presbyterian/St. Lukes Medical Center. Denver. Colorado. This studv was presented at the Symposium on Physiologkc and Pathologic Stress Factors in Musical Performance, University of Rochester Medical Center and the Eastman School of Music on April 29. 1981. Reguests for reprints should be addressed to Dr. C. 6. Brantigan, 1748 Lafayette Street, Denver, Colorado 80218. Manuscript accepted September 28, 1981.

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Stage fright, physiologically the “fight or flight” reaction, is a disabiing condition to the professional muslcian. Because it is mediated by the sympathetic nervous system, we have investigated the effects of beta blockade on musical performance with propranolol In a double blind fashion and the effects of beta stimulatlon using terbutallne. Stage fright symptoms were evaluated in two trials, which included a total of 29 subjects, by questionnaire and by the State Trait Anxiety Inventory. Quality of musical performance was evaluated by experienced music critics. Beta blockade eliminates the physical impediments to performance caused by stage fright and even eliminates the dry mouth so frequently encountered. The quality of musical performance as judged by experienced music critics is significantly improved. This effect is achieved without tranquilization. Beta stimulating drugs increase stage fright problems, and should be used in performing musicians only afler consideration of the detrimental effects which they may have on musical performance. Stage fright is an ubiquitous problem which most of us find bothersome and unpleasant. To a performing musician, however, stage fright may not be the trivial problem that it is to the physician. Because tachycardia, sweaty palms, cardiac irregularities, tremors, hypertension, tight breathing, nausea and the urge to micturate are true physical impediments to musical performance, stage fright may disable a recital artist. An organ recitalist cannot play Max Reger’s “Fantasy and Fugue on BACH” with shaking hands. Pharmacologic control of these effects has been achieved by the use of alcohol and/or tranquilizers, often at the expense of the brilliance and sensitivity of the performance itself. Since, from a physiologic standpoint, stage fright is the fight or flight reaction mediated by the sympathetic adrenal axis, we and other investigators have considered the use of sympathetic blocking agents as treatment. Herein, we further delineate the effects of beta sympathetic blockade and beta sympathetic stimulation on performance anxiety.

MATERIALS AND METHODS These studies were carried out in the Music Department of the University of Nebraska in January 1980, and at the Juilliard Theatre at the Juilliard School in May 1980. The study at the University of Nebraska was approved by the Institutional Review Board of that institution, and consisted of a double-blind crossover study of the effects of propranolol and placebo given 1.5 hours before recitals on two successive days. The 13 subjects were predominantly musical per-

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formance students from the local colleges and universities. The audience consisted of fellow study participants and interested faculty members. Due to difficulties experienced in other studies in maintaining the level of stress on the second day, the audience was reinforced by a local television crew that taped during the entire second performance. The study at the Juilliard School in New York was scheduled with the help of the New York Philharmonic Orchestra officials and consisted of a double-blind crossover study of the effects of propranolol and placebo taken 1.5 hours before a recital. The audience consisted of a few interested staff members of the Orchestra and the School. The 16 subjects were members of the Orchestra, students at the School, or professional musicians interested in the problems of stage fright. No attempts were made to artificially increase the stress of the situation. Although all subjects were also given the opportunity to participate in a three-way study which included the beta stimulator, terbutaline, only seven wished to participate. For these seven subjects, the beta stimulator was given on the third day so that the experimental conditions involving beta blockade and placebo would be identical for all subjects. All subjects received a detailed briefing before the start of the experiment. Each subject passed a brief history and physical examination. All subjects were given the opportunity to discuss the experiments following their conclusions. Continuous telemetric monitoring of the electrocardiogram was carried out with samples of each subjects EKG saved for subsequent study. Blood pressure was recorded at the time of initial physical examination, and before and after each performance. Subjects were observed during the performance for outward signs of stage fright. The subjects reactions to each phase of the experiment were monitored after each performance using questionnaires directed toward the various aspects of stage fright. Scores of questions were grouped into three categories for statistical analysis: overall performance, nervousness and physical symptoms. The State Trait Anxiety Inventory was administered. Comments were also solicited. Each subject was asked for an evaluation of performances. Performances were recorded during both trials and, at the University of Nebraska, the recordings were used to enable members of the music faculty to make a blind evaluation. In the New York study, quality of performance was evaluated during the actual performance by Carlos Moseley of the Philharmonic, Bertha Melnik of the Juilliard School and by the musician-author in a blind fashion. During the Nebraska study an attempt was made to obtain data on the dry mouth phenomenon described by some prominent brass players as a manifestation of stage fright or even of beta blockade. Each subject was asked to place a dental cotton roll at the outlet of Stensen’s duct for 10 minutes immediately after performing. These rolls were sealed in an airtight vial and frozen. When all specimens were obtained, the vials were weighed on a Mettler Balance@, desiccated and weighed again to determine the amount of saliva. In addition, the subjects were asked to submit samples of unstimulated saliva collected the night before their first performance and immediately after each performance thereafter. These were frozen pending determination of salivary sodium and potassium concentrations using standard laboratory techniques.

L

ET AL.

30 lb terbutaline

placebo

propranolol

Figure 1. Beta effects on pulse rate and blood pressure. No statistically significant difference was found in the mean blood pressure whether terbutaline, placebo or propranolol was taken. A dramatic decrease in the maximum observed pulse rate and average pulse rate was seen. Statistical evaluation of data was carried out by applying the paired t test to available data using the Applied Statistics Module of the Texas Instruments TI 59 Calculator@. RESULTS

Physical Evaluation. No significant disturbance was noted in any subject. tractions, both atrial and ventricular

cardiac rhythm Premature con-

in origin, were occasionally seen in subjects irrespective of the medication administered. Average heart rates in excess of 130/min were noted following the administration of placebo in both study groups. Beta blockade produced a dramatic decrease in maximum and average heart rate (p
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TABLE I

ET AL

Beta Effects on Pulse and Blood Pressure (New York Study) Beta Stimulation

TABLE II

Placebo

Beta Blockade 100 f 8

Post-performance blood pressure (mm Hg f SD)

97 f 3

101 f 9

Average pulse during performance (beats/min f SD)

123 f 26

130 f 24

91*

12

Maximum pulse during performance (beatslmin f SD)

141 f 27

148 f 25

104 f

14

Effect Of Stage Fright and Beta Blockade on Salivary Electrolvtes Numberof Control

Sodium (meq/dl f SD) Potassium (meq/dl f SD) Weight (g)

10 10 13

10.6 f 5.3 21.8 f 7.4

Placebo 7.8 f 2.4 29.8 f 6.0 1.05 f 0.43

Beta Blockade 9.5 f 4.7 29.5 f 6.5 1.21 f 0.50

Statistics were obtained by the paired t test. Sodium: Beta blockade vs control = not significant; Placebo vs control = p <0.05; Beta blockade vs placebo = p
‘.o

\ . trrb;talln.

placebo

OJ Anervous

. Propranolol

Vgure2. Beta effects on stage fright. In both the Nebraska study and the New York study the responses to questions pertaining to the overall sensation of nervousness improved in a statistically significant fashion. The score of responses to questions pertaining to physical manifesfations of stage fright improvedin both studies. Performance improved as well but the difference was not statistically significant Questions aimed at the physical manifestations of stage fright reflected an increase over placebo when terbutaline was given; a fiend much more pronounced in the subjects ‘ open-endedcomments.

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salivary potassium was also produced (p
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(stage fright or state) but not in the subjects overall level of anxiety (trait). Likewise, the administration of terbutaline caused an increase in situational anxiety. Although these data fall on a statistical curve, suggesting that beta stimulation increases situational anxiety and beta blockade ameliorates it, only the increased score attained with terbutaline achieved statistical significance at the p <0.05 level. The changes noted in the overall level of anxiety (trait) caused by terbutaline were not statistically significant. Note the high percentile score for all musicians who participated in the New York study. In the Nebraska study, state and trait data were similar but percentile scores were in the 50 percent range. Although the performers assessment of their own performances favored the beta-blocking drug in the Nebraska study, the incidence of random errors was too high for meaningful evaluation by the music faculty. In the New York study, on the other hand, an overwhelming preference for the beta-blockade performance was expressed by the evaluators (Table Ill). No significant difference between judges was found using Cochrane’s Q test. After pooling the three judge’s decisions and ignoring “NP” (no preference) decisions, there were 25 decisions of a possible 28 favoring the use of propranolol or 89.3 percent. This differs significantly from chance (P
ET AL.

160

1 .

12Q

pulse

80, terbutallno I:1

placebo

propranolol

n-14

a=14

Figure 3. Beta effects on the State Trait Anxiety Inventory. Propranolol produced a decrease in anxiety in the state portion of the anxiety inventory which did not achieve statistical significance. Terbutaline caused a statistically significant increase (p < 0.02) in anxiety as demonstrated by the state examination. Both raw data andpercentile scores are plotted.

of music before juries made up of overly critical professors. Negative feedback is common. Such training not only teaches musical performance but also actually cultivates the stage fright response. To the musician, two elements, performance and anxiety, are paired so often that when one appears the other invariably follows.

TABLE Ill

Performance Preferences (New York Study)

Subject no.and Evaluators WI-Evaluation Thomas Brantban CarlosMoaalev BerthaMelnlk 1, 8 2. B 3, 4 5, B 6, A 7, A 6. B 9, A

10, B 11, A 12’

traditional musical training coerces the neophyte mu-

sician into repeated high pressure performance situations for which he is relatively unprepared. The aspiring musician begins his training by auditioning before a highly critical audience to gain admission to the conservatory. His musical training experience is characterized by frequent, relatively unpolished performances

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13, B 14, B 15, B

16, B

B=

B B B B B 0 B A B 0 B

B B B -

B A 0 B B 0

preference for performance with beta-blocker: for performance with placebo. Subject had adverse reaction to placebo.

B B B B 0 B 0 0 A = preference

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Stage fright learned during conservatory training is reinforced by experience performing. For example, the brass player, recently graduated from a conservatory, auditions for a symphony position. He is competing with perhaps 100 other aspiring applicants for one job. Following acceptance into the orchestra, solos, either in a concerto context or as a member of the orchestra, immediately exposes his errors to the criticism of both his professional colleagues and a large audience. A performer beset by fear finds his body reacting, as it would when facing a hostile mob or a sabertooth tiger, with the fight or flight reaction. Subtle intellectual decision making is chemically discouraged in preparation for a massive physical effort, but what is good for fighting tigers or a hostile mob is not necessarily good for performing music; subtle nuances of interpretation are required rather than mass action. The sympathetic alarm response is not only inappropriate to a performance situation, but caused self-poisoning with catecholamines. The magnitude of stress experienced by professional performing musicians is greatly underestimated by those physicians who have never experienced such a degree of stress themselves. The traditional responses of the physicians to the professional musician with stage fright are all seriously flawed. Physicians prescribe tranquilizers, deny that stage fright is a significant physical problem, or more commonly, insist that the problem will go away with maturity and experience. Although tranquilizers may relieve the symptoms of anxiety, they also cause deterioration in the musicians ability to perform. Herein, we have documented the physical nature of the problem. To dismiss serious research into this problem as “an amusing perspective on the terrors of studying music,” as was recently done by Swartz [ 11, shows a lack of understanding of the realities of musical performance. Stage fright does not go away by itself. Experience, exposure and skill may not make the problem disappear either. Some of the worlds foremost musicians have been incapicitated by it. Vladimir Horowitz is said to suffer terribly from it, declining public performance for a period of 15 years [ 21. Arthur Rubinstein calls it “the price I have to pay for my wonderful life” [2]. Pablo Casals, in Jose Maria Corredor’s book, Conversations with Casals, confessed that the thought of public performance gives him nightmares [3]. To say that these men are immature musicians shows a lack of musical knowledge. To say that performers so affected by the stresses of their performance should not be involved in music is to discard many of music’s greatest practitioners. There must be a better solution. The beta effects on stage fright must be considered in the context of the larger concept of morbid anxiety. Tyrer and Lader [4], and other investigators have ar-

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ET AL.

bitrarily divided this broad disorder into the overlapping categories of neurotic and somatic anxiety. In neurotic anxiety the disability originates primarily in the central nervous system. Neurotic anxiety is a psychologic disability that produces physical symptoms. Studies of patients with neurotic anxiety treated with the same low doses of beta blocking drugs as were used in this study revealed poor results. As Suzman [5] has pointed out, patients whose neurotic anxiety has responded to the administration of propranolol have required immense doses (1.2 g/day). In somatic anxiety true disability arises from physical effects. Sympathetic activation produces physical symptoms which the central nervous system interprets as anxiety and then reinforces with further sympathetic stimulation. In spite of the psychologic manifestations, the true disability is primarily physical rather than psychological. Studies carried out using beta-blocking drugs in patients with somatic anxiety have shown positive therapeutic effects. Although we must not minimize the importance of central or neurotic anxiety, in our experience, professional musicians with significant stage fright almost always fall into the somatic group. Although the presence of beta adrenergic receptors in the central nervous system has been documented both biochemically and physiologically, and some beta-blocking drugs do cross the blood-brain barrier [6], we believe that the site of action of beta-blocking drugs used to treat stage fright is peripheral rather than central. Psychosis, occurring with the administration of propranolol, is unquestionably a central nervous system effect as is depression seen with the long-term administration of the drug for coronary artery disease [ 71. On the other hand, studies such as the thorough one by Lader and Tyrer [8] have consistently failed to show a central nervous system effect after the administration of single doses of propranolol up to 120 mg. Studies of performance and examination situations have uniformly failed to show any decrement in intellectual function and have often shown improvement [ 9- 121. Stage fright symptoms can be both produced and blocked by peripherally-acting drugs. Particularly when administered with the proper external cues, catecholamine infusion can produce all of the symptoms we associate with stage fright. It is well known that the administration of adrenalin (which does not cross the blood-brain barrier) [ 191, or the presence of a phenochromocytoma, can cause anxiety. Intraarterial isoproterenol causes tremor which is prevented by infusion of propranolol [ 131. Beta-blocking drugs such as practolol, which do not cross the blood-brain barrier, have been just as effective as propranolol in treating patients with somatic anxiety [ 141. A peripheral mechanism of action is attractive because it explains why drugs such as practolol are effective and why

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propranolol can be given in effective doses without any detectable effects in the central nervous system and without any of the detremental effects on intellectual function that are so often seen with mood altering drugs. Previous studies have been carried out documenting the effectiveness of beta blockade in the treatment of stage fright in musicians. In 1974, Liden and Gottfries [ 151 reported the use of alprenolol in a double-blind crossover experiment in 15 volunteer subjects from a professional symphony orchestra. Although not all of the subjects completed the experiment, alprenolol had an ameliorating effect on symptoms caused by catecholamines. In 1977, James et al. [9] studied the effect of 40 mg of oxyprenolol on stage fright in 24 musicians in a double-blind crossover trial. Although their study was carried out under stressful conditions-a recital in Wigmore Hall before an invited audience which was recorded by a battery of “very obvious” microphones-average heart rate with placebo was only 99/min decreasing to 75/min with oxyprenolol. Since it is unlikely that our model is more stressful, the high maximum pulse rates we have consistently documented in our trials simply show that telemetric monitoring is required for accurate pulse rate determinations during performance. James and colleagues [ 9] documented a decrease in the physical manifestations of stage fright, and an overall improvement in performance averaging 5 percent, although in some subjects there was a 30 to 73 percent improvement in total score. The effects documented were most dramatic in subjects with the highest overall anxiety level, as they were in our study. In our previous study [ 111, we demonstrated a significant decrease in the physical manifestations of anxiety, but also detected a much less significant improvement in performance. At the time, we attributed this to the high incidence of random errors in our performers, and an inability, also experienced in the James study [9], to achieve the same level of stress on the second day of performance. The present study does show a statistically significant improvement in overall musical performance using beta blockade. The study reported here, and the research done by James and associates [ 91, documents the striking effectiveness of beta-blocking drugs in treating performers with stage fright. Because these drugs are competitive inhibitors, most of the anxiolytic effect is achieved by small doses. Increasing doses causes little additional effect [ 161 and thus, there is little tendency for the musician to increase the dose. Nevertheless, our scientific documentation poses an ethical dilemma. Beta-blocking agents are potent drugs. Serious consequences can result if they are given to the asthmatic patient or to the patient with cardiac conduction system

BETA STIMULATION

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ET AL.

disease. Withdrawal from beta-blocking drugs after prolonged continuous use may be hazardous. None of the investigators who have been involved in this type of research wish to start another drug counter-culture-the performing musician with long-term dependence on beta-blocking drugs. For this reason, we must consider how these drugs should be used in performance anxiety. For the performing musician with a medical need for drug therapy, in which one of the drugs of choice is a beta-blocking drug, the choice is relatively easy. For performers who are so incapacitated by performance anxiety that their livelihood is in jeopardy an argument can be made for the use of a beta-blocking drug. Since a bricklayer with angina is a candidate for drug therapy with beta-blocking agents, perhaps a similarly disabled musician would likewise be a candidate. In cases of this sort, decisions must be made by physicians on an individual basis. In contrast to these situations, the indiscriminate passing of this drug from student to student in preparation for final exams is, unfortunately, being practiced but is roundly condemned. As scientific investigators, we think that beta blockade in cases of performance anxiety is only appropriate under medical supervision. Under such supervision, the drug can be appropriately used for isolated episodes of severe stress, such as a major recital cx, perhaps, an address at a national scientific meeting. Additionally, the drug should be used as a part of a coordinated retraining program aimed at teaching musicians not to have stage fright. Although we have little experience with this combination, it appears that psychologic techniques, such as self-hypnosis, when used in combination with an explanation of the physiology of stage fright and a temporary pharmacologic solution, should be effective retraining. CONCLUSIONS (I) Beta blockade effectively eliminates the physical impediments to performance caused by stage fright; (2) By eliminating the physical impediments to performance, beta blocking drugs can increase the quality of musical performance as judged by experienced musical critics. This effect is achieved not by giving the performer any increased ability or by tranquilization, but by removing physical impediments; (3) Beta stimulating drugs increase stage fright problems and should be used in performing musicians only after consideration of the detrimental effects which they may have on the subjects performance; (4) Beta blocking drugs given in a musical performance situation caused an increase in salivary volume and cause salivary sodium to return to control levels. Salivary potassium is increased by the performance situation and remains increased after beta blockade.

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ACKNOWLEDGMENTS

partment of the University of Colorado Health Sciences Center for advice in the statistical treatment of data, and to George Ritchie of the Music Department of the University of Nebraska for his help with arrangements on that campus. James McGrew of Digital Bionics supplied monitoring equipment and Dr. Irving Mandel provided valuable advice on the salivary experiments. Dr. Charles Kavalovski provided valuable insight into scientific approaches to performing musicians.

We would like to express our appreciation to Carlos Moseley of the New York Philharmonic for his help in conducting this study. Without the benefit of his advice and technical assistance this study would have been impossible. Bertha Melnik of the Juilliard School provided valuable help in evaluating musical performance. We also thank Strother Walker of the Biometrics De-

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