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Reducing the somatic manifestations of anxiety by beta-blockade — A study of stage fright
Journal of OPergamon
~~1.22, PP. 327:337.0022-3999f78foao~-o327 $oz.oofo Psychosomatic Research, Press Ltd. 1978. Printed in GreatBritain.
REDUCING THE SOMATIC MANIFESTATIONS OF ANXIETY BY BETA-BLKXADE - A STUDY OF STAGE FRIGHT I.M.James, R.M.Pearson, D.N.W.Griffith and Patricia Newbury Section of Clinical Pharmacology, Academic Department of Medicine, Royal Free Hospital and S. H. Taylor University Department of Cardiovascular Studies and Department of Medical Cardiology, The General Infirmary, Leeds
328
I. M. James
et al.
THE EFFECT OF BETA-ADRENOCEPTOR SOMATIC MANIFESTATIONS
BLOCKADE ON THE
OF ANXIETY.
A STUDY OF
STAGE FRIGHT I.M.James, R.M.Pearson, D.N.W.Griffith Patricia Newbury, Section of Clinical Pharmacology, Academic Department of Medicine, Royal Free Hospital
and
and S.H. Taylor University Department of Cardiovascular Studies and Department of Medical Cardiology, The General Infirmary, Leeds In modern life skilled tasks are often carried out under The relationship between apprehadverse and stressful conditions. ension and performance of such tasks has been described by the Initially performance 'Yerkes - Dodson' law (Tyrer, 1977). improves as apprehension increases, largely due to increased motivFurther anxiety however is not associated ation of the subject. with additional improvement in performance and if apprehension This is continues to increase, p erformance rapidly deteriorates. essentially what happens in stage-fright. The psychological and physiological mechanisms responsible for this complex interaction are obscure, but almost certainly involve the sympathoadrenal system. Mental stress is often associated with sympathoadrenal activation resulting in the clinical manifestations of palpitations, hyperventilation, sweating and Such sensations often enhance the anxiety in susceptible tremor. individuals with the result that the very sensations are associated The exact mechanisms involved in the with feelings of fear. establishment of such a vicious circle are unknown, but the deleterious effect of fear and anxiety on the performance of skilled task is undoubted. Traditionally, centrally acting drugs have been used in an attempt to combat the adverse effects of anxiety on performance. However, their administration is associated with unwanted sedation, which in turn leads to a deterioration in performance. The use of beta-adrenoceptor blocking drugs to treat the somatic manifestations of anxiety was first suggested by Granville Grossman and Turner in 1966, and their efficacy in this respect has been confirmed by Tyrer and Lader (1973). It is to be expected that the somatic accompaniments of anxiety would lead to a deterioration in performance of musicians, particularly those playing string instruments because of tremor. This study was therefore designed to examine the effects of a beta-adrenoceptor antagonist on the examination performance of musicians playing string instruments. METHODS Subjects Twenty four string player volunteers, including six males, were recruited from the London Colleges and Acadamies of Music; all were highly trained string players. None claimed to suffer from undue nervousness and none suffered from any coincidental illness.
A Study of Stage Fright
329
Informed consent was obtained from all. Design A conventional two way randomized double-blind cross-over design was employed. Players were asked to give a 15 minute recital on two occasions, one after placebo and one 90 minutes after 40 mg oral oxprenolol. They were given two pieces in The advance to study, one of which had to be committed to memory. study was carried out under 'concert' conditions at the Wigmore Hall before an invited audience, including the musical assessors. Rre-perfoiaance measurements Anxiety was scored by a graded scale 1 (nonchalant) to 6 (panicky) and also by a visual analogue scale (VARS) calibrated from 0 (relaxed) to 100 (petrified). Pallor, hand sweating, hand coldness and tremor were graded and blood pressure and heart rate measured before the performance. Musical Assessment Musical assessment was carried out by two experienced music comoetition adjudicators (Turton and Strub. London College of Music). Each of the foilowing musically important points were scored out of. 10: left hand - shifting, intonation, vibrato, musicianship; right hand - lack of tremor, bowling, musicianship. Memory was also scored out of 10. Post Recital Assessment After recital, the musicians were asked to record problems with vibrato, intonation, bowling or tremor, how they rated their performance and how they now felt; a graded analogue scale was used for each. Statistics Data expressed as mean + standard error or mean throughout. Statistical significances were calculated from Students paired 't' test and accepted as different at the 95% level of confidence. RESULTS Nervousness There was an overall statistically significant decrease in nervousness rated both by visual analogue scale 57 mm+ SEM 4.0 to 46mm 2 SM 4.8 and by graded scale 3.71 + 0.23 to 2.92 + 0.24 (SEM). Tremor was si nificantly less on oxprenolol (1.50 + O.l??)compared with ulacebo $2.12 + 0.16). Facial oallor on the-other hand increased from O.25-+ 0.9.to 0.63 + 0117. Sweaty hands and cold hands tended to be 1%~ marked on Tirug,but these changes did not reach significance. Pulse rate was reduced significantly from beats/min. Blood pressure was unchanged. 99 2 to 75 fMusical Assessment (Figures 1 - 5) There was a significant improvement in intonation left hand musicianship, tremor and right hand musicianship (R.H.M.) Changes in the other variables did not reach statistical significance, although there was a trend towards improvement in all instances. The total score for each player showed an overall improvement on oxprenolol, with three of the four subjects with the lowest scores on placebo improving the most.
330
I.
M. James et
al.
FIGURE 1 I’NTONATION
I
placebo
8
6
N’24 P ( 0.02
oxprenolol
A Study
FIGUIiE
placebo
ia
7
2
L.H.M.
of
Stage
Fright
331
332
I. M. James
FIGURE
3
et al.
TREMOR
placebo
oxprenolol
1C
9
8
7
6
5
4
3
N-24 PsO.02
A Study
FIGURE
4
of
Stage
333
Fright
R.H.M.
oxprenolol
placebo 10.
9
8
N= 24 P G0.05
I.
334
FIGURE 5
M. James
et al.
TOTAL
oxprenolol
placebo 65
60
55
30
25
N= 24 PsO.01
A Study of Stage Fright
335
Comparison of scores on first day between drug and placebo were significantly different; this difference was not maintained at the second session, due to an increase in placebo score (Table I). There was no adverse effect of oxprenolol on the memory score. TABLE 1. Mean of Total Marks allotted by Musical Assessors 1st Session
2nd Session
Oxprenolol
51.5
51.1
Placebo
47.1
50.3
4.4*
Difference Significantly
different
from Placebo
0.8 at 1% level.
n = 24. Self Assessment
Post Performance
Problems with tremor and stiffness were rated as being Intonation was as much a significantly less on oxprenolol. problem to players as before, despite the judges' rating of There was a significant improvement in how musicians improvement. felt they had performed and they were also happier post performance. Comparison of actual performance marks with performers self assessment showed that on oxprenolol 15 correctly assessed themselves as Three assessed themselves as better when there had either better. been no change or a slight deterioration and six as worse when there had been no change or improvement. DISCUSSION The finding of an overall improvement in musical performance on oxprenolol and the difference in drug effect on the first and second days are the two most important observations to emerge from this study. With regard to the former, oxprenolol attenuated many of the adverse somatic effects of mental stress on artistic performance; an indication of the somatic effects was the significant descrease in muscle tremor and pulse rate. It is somewhat difficult to evaluate the improvement in musicianship and intonation in precise physiological terms, but it is obvious that skill, judgement and co-ordination are all involved. It is also possible that some of these changes in musical performance may be only indirectly due to the drug, e.g. removal of a major problem such as bow tremor may allow subjects to concentrate on problems such as An illustration of this 'playing in tune' more efficiently. indirect effect of the drug is that some players only noticed errors in their playing after oxprenolol although the same errors went unnoticed on placebo. The improvement in the piacebo score on the second performance is intriguing and an important consideration in any programme designed to test the somatic manifestations of mental stress. It has been noticed in laboratory tests using the stress of time mental arith:netic (Taylor, 1?7i+) and i!!ipliesthat the need for damping the somatic sequelae decreases as the stressful situation becomes familiar. Few studies have been reported which emphasize this imaortant fact, namely that in situations of expected subacute stress the somatic responses decrease with repeated exposure; the majority of studies have been concerned only with the first test exposure. This holds the important therapeutic implication that attenuation of the physical accompaniments of
336
I. M. James et al.
mental stress by peripherally acting sympathetic beta-receptor blocking drugs can be expected to be maximally effective at the first exposure to stress. The potential usefulness of beta-adrenoceptor blocking drugs in the situation described in this report requires amplification. Anxiety in response to the mental stress of playing before an audience is not confined to the younger musici.ans, and neither is Both circumstexperience a safeguard against artistic mistakes. ances can lead to a vicious circle of apprehension - sympathoadrenal overactivity - somatic sequelae including tremor - artistic mistakes anxiety etc. In this situation many players resort to tranquillizers or alcohol, but neither break the chain of reaction at its most effective and efficacious point, namely the peripheral Betareceptor responsible for the unwanted somatic effects. blocking drugs used intermittently in relatively small doses may thus enable artists such as concert musicians to successfully adapt to stressful occasions. Although the use of drugs in such situations is often deplored, the non-addicting peripherally acting beta-blocking drugs may be more acceptable than the centrally acting Further studies are necessary drugs or alcolhol so often employed. to confirm their efficacy in this and other similar situations. But we submit that these limited observations give cause for optimism in this respect. Summary The effects of oxprenolol 40 mg taken 90 minutes before on the musical performance of 24 string musicians was tested under concert conditions by a double-blind randomized comparison against The drug attenuated the adverse somatic effects of placebo. mental stress on the first musical performance, but there was no significant difference between drug and placebo on the second occasion. Intermittent use of small doses of beta-blocking drugs in this situation has advantages over the use of tranquillizers or alcohol in allaying the physical results of anxiety. Acknowledgments We thank the musicians who volunteered to take part; Plr. Peter Turton and Mr.Harald Strub of the Arriaga String Quarted, the London College of Music and Nr.P.Hemming, Department of Medical Cardiology, The General Infirmary, Leeds for their help with these studies. We also thank Ciba Laboratories for their financial support for the study.
A Study of Stage Fright
337
REFERENCES 1.
Carruthers, M.E. Lancet, 1969, -ii: 1170
2.
Granville-Grossman, K. and Turner, P., Lancet 1966,&: 788
3.
Russek, H-1. and Russek, L-G. "Stress and the Heart". Wheatly, Raven Press, New York, 1977, 15.
4.
Taggart, P. and Carruthers, M. "Stress and the Heart". Ed. D.Wheatly, Raven Press, New York, 1977, 33.
5.
Taggart, P., Carruthers, M. and Somerville, W., Lancet 1973, Q; 341
6.
Taggart, P., Gibbons, D. and Somerville, W., Brit. med. J., 1969, -iv: 130
7.
Taylor, S.H. "Prospects in the Management of Ischaemic Heart Disease", 1974, CIBA Horsham, 244.
8.
Taylor, S.H. and Meeran, M.K., Brit. med. J., -iv: 257
9.
Turner, P. and Hedges, A. New Perspectives in Beta Blockade. Int. Symp., Scanticon, Aarhus, Denmark, 1972. CIBA Laboratories, 269.
IO.
Tyrer, P.J. and Lader M.H. (1973) 418.
11.
Tyrer, P.J. 1977.
Ed.D.
Clin. Pharmac. Ther. l4,
Practioner 219, 479
~~1.22, PP. 327:337.0022-3999f78foao~-o327 $oz.oofo Psychosomatic Research, Press Ltd. 1978. Printed in GreatBritain.
REDUCING THE SOMATIC MANIFESTATIONS OF ANXIETY BY BETA-BLKXADE - A STUDY OF STAGE FRIGHT I.M.James, R.M.Pearson, D.N.W.Griffith and Patricia Newbury Section of Clinical Pharmacology, Academic Department of Medicine, Royal Free Hospital and S. H. Taylor University Department of Cardiovascular Studies and Department of Medical Cardiology, The General Infirmary, Leeds
328
I. M. James
et al.
THE EFFECT OF BETA-ADRENOCEPTOR SOMATIC MANIFESTATIONS
BLOCKADE ON THE
OF ANXIETY.
A STUDY OF
STAGE FRIGHT I.M.James, R.M.Pearson, D.N.W.Griffith Patricia Newbury, Section of Clinical Pharmacology, Academic Department of Medicine, Royal Free Hospital
and
and S.H. Taylor University Department of Cardiovascular Studies and Department of Medical Cardiology, The General Infirmary, Leeds In modern life skilled tasks are often carried out under The relationship between apprehadverse and stressful conditions. ension and performance of such tasks has been described by the Initially performance 'Yerkes - Dodson' law (Tyrer, 1977). improves as apprehension increases, largely due to increased motivFurther anxiety however is not associated ation of the subject. with additional improvement in performance and if apprehension This is continues to increase, p erformance rapidly deteriorates. essentially what happens in stage-fright. The psychological and physiological mechanisms responsible for this complex interaction are obscure, but almost certainly involve the sympathoadrenal system. Mental stress is often associated with sympathoadrenal activation resulting in the clinical manifestations of palpitations, hyperventilation, sweating and Such sensations often enhance the anxiety in susceptible tremor. individuals with the result that the very sensations are associated The exact mechanisms involved in the with feelings of fear. establishment of such a vicious circle are unknown, but the deleterious effect of fear and anxiety on the performance of skilled task is undoubted. Traditionally, centrally acting drugs have been used in an attempt to combat the adverse effects of anxiety on performance. However, their administration is associated with unwanted sedation, which in turn leads to a deterioration in performance. The use of beta-adrenoceptor blocking drugs to treat the somatic manifestations of anxiety was first suggested by Granville Grossman and Turner in 1966, and their efficacy in this respect has been confirmed by Tyrer and Lader (1973). It is to be expected that the somatic accompaniments of anxiety would lead to a deterioration in performance of musicians, particularly those playing string instruments because of tremor. This study was therefore designed to examine the effects of a beta-adrenoceptor antagonist on the examination performance of musicians playing string instruments. METHODS Subjects Twenty four string player volunteers, including six males, were recruited from the London Colleges and Acadamies of Music; all were highly trained string players. None claimed to suffer from undue nervousness and none suffered from any coincidental illness.
A Study of Stage Fright
329
Informed consent was obtained from all. Design A conventional two way randomized double-blind cross-over design was employed. Players were asked to give a 15 minute recital on two occasions, one after placebo and one 90 minutes after 40 mg oral oxprenolol. They were given two pieces in The advance to study, one of which had to be committed to memory. study was carried out under 'concert' conditions at the Wigmore Hall before an invited audience, including the musical assessors. Rre-perfoiaance measurements Anxiety was scored by a graded scale 1 (nonchalant) to 6 (panicky) and also by a visual analogue scale (VARS) calibrated from 0 (relaxed) to 100 (petrified). Pallor, hand sweating, hand coldness and tremor were graded and blood pressure and heart rate measured before the performance. Musical Assessment Musical assessment was carried out by two experienced music comoetition adjudicators (Turton and Strub. London College of Music). Each of the foilowing musically important points were scored out of. 10: left hand - shifting, intonation, vibrato, musicianship; right hand - lack of tremor, bowling, musicianship. Memory was also scored out of 10. Post Recital Assessment After recital, the musicians were asked to record problems with vibrato, intonation, bowling or tremor, how they rated their performance and how they now felt; a graded analogue scale was used for each. Statistics Data expressed as mean + standard error or mean throughout. Statistical significances were calculated from Students paired 't' test and accepted as different at the 95% level of confidence. RESULTS Nervousness There was an overall statistically significant decrease in nervousness rated both by visual analogue scale 57 mm+ SEM 4.0 to 46mm 2 SM 4.8 and by graded scale 3.71 + 0.23 to 2.92 + 0.24 (SEM). Tremor was si nificantly less on oxprenolol (1.50 + O.l??)compared with ulacebo $2.12 + 0.16). Facial oallor on the-other hand increased from O.25-+ 0.9.to 0.63 + 0117. Sweaty hands and cold hands tended to be 1%~ marked on Tirug,but these changes did not reach significance. Pulse rate was reduced significantly from beats/min. Blood pressure was unchanged. 99 2 to 75 fMusical Assessment (Figures 1 - 5) There was a significant improvement in intonation left hand musicianship, tremor and right hand musicianship (R.H.M.) Changes in the other variables did not reach statistical significance, although there was a trend towards improvement in all instances. The total score for each player showed an overall improvement on oxprenolol, with three of the four subjects with the lowest scores on placebo improving the most.
330
I.
M. James et
al.
FIGURE 1 I’NTONATION
I
placebo
8
6
N’24 P ( 0.02
oxprenolol
A Study
FIGUIiE
placebo
ia
7
2
L.H.M.
of
Stage
Fright
331
332
I. M. James
FIGURE
3
et al.
TREMOR
placebo
oxprenolol
1C
9
8
7
6
5
4
3
N-24 PsO.02
A Study
FIGURE
4
of
Stage
333
Fright
R.H.M.
oxprenolol
placebo 10.
9
8
N= 24 P G0.05
I.
334
FIGURE 5
M. James
et al.
TOTAL
oxprenolol
placebo 65
60
55
30
25
N= 24 PsO.01
A Study of Stage Fright
335
Comparison of scores on first day between drug and placebo were significantly different; this difference was not maintained at the second session, due to an increase in placebo score (Table I). There was no adverse effect of oxprenolol on the memory score. TABLE 1. Mean of Total Marks allotted by Musical Assessors 1st Session
2nd Session
Oxprenolol
51.5
51.1
Placebo
47.1
50.3
4.4*
Difference Significantly
different
from Placebo
0.8 at 1% level.
n = 24. Self Assessment
Post Performance
Problems with tremor and stiffness were rated as being Intonation was as much a significantly less on oxprenolol. problem to players as before, despite the judges' rating of There was a significant improvement in how musicians improvement. felt they had performed and they were also happier post performance. Comparison of actual performance marks with performers self assessment showed that on oxprenolol 15 correctly assessed themselves as Three assessed themselves as better when there had either better. been no change or a slight deterioration and six as worse when there had been no change or improvement. DISCUSSION The finding of an overall improvement in musical performance on oxprenolol and the difference in drug effect on the first and second days are the two most important observations to emerge from this study. With regard to the former, oxprenolol attenuated many of the adverse somatic effects of mental stress on artistic performance; an indication of the somatic effects was the significant descrease in muscle tremor and pulse rate. It is somewhat difficult to evaluate the improvement in musicianship and intonation in precise physiological terms, but it is obvious that skill, judgement and co-ordination are all involved. It is also possible that some of these changes in musical performance may be only indirectly due to the drug, e.g. removal of a major problem such as bow tremor may allow subjects to concentrate on problems such as An illustration of this 'playing in tune' more efficiently. indirect effect of the drug is that some players only noticed errors in their playing after oxprenolol although the same errors went unnoticed on placebo. The improvement in the piacebo score on the second performance is intriguing and an important consideration in any programme designed to test the somatic manifestations of mental stress. It has been noticed in laboratory tests using the stress of time mental arith:netic (Taylor, 1?7i+) and i!!ipliesthat the need for damping the somatic sequelae decreases as the stressful situation becomes familiar. Few studies have been reported which emphasize this imaortant fact, namely that in situations of expected subacute stress the somatic responses decrease with repeated exposure; the majority of studies have been concerned only with the first test exposure. This holds the important therapeutic implication that attenuation of the physical accompaniments of
336
I. M. James et al.
mental stress by peripherally acting sympathetic beta-receptor blocking drugs can be expected to be maximally effective at the first exposure to stress. The potential usefulness of beta-adrenoceptor blocking drugs in the situation described in this report requires amplification. Anxiety in response to the mental stress of playing before an audience is not confined to the younger musici.ans, and neither is Both circumstexperience a safeguard against artistic mistakes. ances can lead to a vicious circle of apprehension - sympathoadrenal overactivity - somatic sequelae including tremor - artistic mistakes anxiety etc. In this situation many players resort to tranquillizers or alcohol, but neither break the chain of reaction at its most effective and efficacious point, namely the peripheral Betareceptor responsible for the unwanted somatic effects. blocking drugs used intermittently in relatively small doses may thus enable artists such as concert musicians to successfully adapt to stressful occasions. Although the use of drugs in such situations is often deplored, the non-addicting peripherally acting beta-blocking drugs may be more acceptable than the centrally acting Further studies are necessary drugs or alcolhol so often employed. to confirm their efficacy in this and other similar situations. But we submit that these limited observations give cause for optimism in this respect. Summary The effects of oxprenolol 40 mg taken 90 minutes before on the musical performance of 24 string musicians was tested under concert conditions by a double-blind randomized comparison against The drug attenuated the adverse somatic effects of placebo. mental stress on the first musical performance, but there was no significant difference between drug and placebo on the second occasion. Intermittent use of small doses of beta-blocking drugs in this situation has advantages over the use of tranquillizers or alcohol in allaying the physical results of anxiety. Acknowledgments We thank the musicians who volunteered to take part; Plr. Peter Turton and Mr.Harald Strub of the Arriaga String Quarted, the London College of Music and Nr.P.Hemming, Department of Medical Cardiology, The General Infirmary, Leeds for their help with these studies. We also thank Ciba Laboratories for their financial support for the study.
A Study of Stage Fright
337
REFERENCES 1.
Carruthers, M.E. Lancet, 1969, -ii: 1170
2.
Granville-Grossman, K. and Turner, P., Lancet 1966,&: 788
3.
Russek, H-1. and Russek, L-G. "Stress and the Heart". Wheatly, Raven Press, New York, 1977, 15.
4.
Taggart, P. and Carruthers, M. "Stress and the Heart". Ed. D.Wheatly, Raven Press, New York, 1977, 33.
5.
Taggart, P., Carruthers, M. and Somerville, W., Lancet 1973, Q; 341
6.
Taggart, P., Gibbons, D. and Somerville, W., Brit. med. J., 1969, -iv: 130
7.
Taylor, S.H. "Prospects in the Management of Ischaemic Heart Disease", 1974, CIBA Horsham, 244.
8.
Taylor, S.H. and Meeran, M.K., Brit. med. J., -iv: 257
9.
Turner, P. and Hedges, A. New Perspectives in Beta Blockade. Int. Symp., Scanticon, Aarhus, Denmark, 1972. CIBA Laboratories, 269.
IO.
Tyrer, P.J. and Lader M.H. (1973) 418.
11.
Tyrer, P.J. 1977.
Ed.D.
Clin. Pharmac. Ther. l4,
Practioner 219, 479