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RUTH ANN McCLAIN, a flutist from Memphis, used to suffer from debilitating onstage jitters.
"My hands were so cold and wet, I thought I'd drop my flute," Ms. McClain said recently, remembering a performance at the National Flute Convention in the late 1980's. Her heart thumped loudly in her chest, she added; her mind would not focus, and her head felt as if it were on fire. She tried to hide her nervousness, but her quivering lips kept her from performing with sensitivity and nuance.
However much she tried to relax before a concert, the nerves always stayed with her. But in 1995, her doctor provided a cure, a prescription medication called propranolol. "After the first time I tried it," she said, "I never looked back. It's fabulous to feel normal for a performance."
Ms. McClain, a grandmother who was then teaching flute at Rhodes College in Memphis, started recommending beta-blocking drugs like propranolol to adult students afflicted with performance anxiety. And last year she lost her job for doing so.
College officials, who declined to comment for this article, said at the time that recommending drugs fell outside the student-instructor relationship and charged that Ms. McClain asked a doctor for medication for her students. Ms. McClain, who taught at Rhodes for 11 years, says she merely recommended that they consult a physician about obtaining a prescription.
Ms. McClain is hardly the only musician to rely on beta blockers, which, taken in small dosages, can quell anxiety without apparent side effects. The little secret in the classical music world -- dirty or not -- is that the drugs have become nearly ubiquitous. So ubiquitous, in fact, that their use is starting to become a source of worry. Are the drugs a godsend or a crutch? Is there something artificial about the music they help produce? Isn't anxiety a natural part of performance? And could classical music someday join the Olympics and other athletic organizations in scandals involving performance-enhancing drugs?
Beta blockers -- which are cardiac medications, not tranquilizers or sedatives -- were first marketed in 1967 in the United States for disorders like angina and abnormal heart rhythms. One of the commonest is propranolol, made here by Wyeth Pharmaceuticals and sold under the brand name Inderal. By blocking the action of adrenaline and other substances, these drugs mute the sympathetic nervous system, which produces fear in response to any perceived danger, be it a sabre-toothed tiger or a Lincoln Center audience.
Even the most skillful and experienced musicians can experience this fear. Legendary artists like the pianists Vladimir Horowitz and Glenn Gould curtailed their careers because of anxiety, and the cellist Pablo Casals endured a thumping heart, shortness of breath and shakiness even as he performed into his 90's. Before the advent of beta blockers, artists found other, often more eccentric means of calming themselves. In 1942, a New York pianist charged his peers 75 cents to attend the Society for Timid Souls, a salon in which participants distracted one another during mock performances. Others resorted to superstitious ritual, drink or tranquilizers. The pianist Samuel Sanders told an interviewer in 1980 that taking Valium before a performance would bring him down from wild panic to mild hysteria.
Musicians quietly began to embrace beta blockers after their application to stage fright was first recognized in The Lancet, a British medical journal, in 1976. By 1987, a survey conducted by the International Conference of Symphony Orchestra Musicians, which represents the 51 largest orchestras in the United States, revealed that 27 percent of its musicians had used the drugs. Psychiatrists estimate that the number is now much higher.
"Before propranolol, I saw a lot of musicians using alcohol or Valium," said Mitchell Kahn, director of the Miller Health Care Institute for the Performing Arts, describing 25 years of work with the Metropolitan Opera orchestra and other groups. "I believe beta blockers are far more beneficial than deleterious and have no qualms about prescribing them."
But use of drugs is still largely secretive. "Inderal is like Viagra," a woodwind player at a major orchestra said. "No one admits to using it because of the implication of weakness." Robin McKee, the acting principal flutist of the San Francisco Symphony, agrees, saying, "It's too bad we're reluctant to talk about using such a great tool."
Indeed, the effect of the drugs does seem magical. Beta blockers don't merely calm musicians; they actually seem to improve their performances on a technical level. In the late 1970's, Charles Brantigan, a vascular surgeon in Denver, began researching classical musicians' use of Inderal. By replicating performance conditions in studies at the Juilliard School and the Eastman School in Rochester, he showed that the drug not only lowered heart rates and blood pressure but also led to performances that musical judges deemed superior to those fueled with a placebo. In 1980, Dr. Brantigan, who plays tuba with the Denver Brass, sent his findings to Kenneth Mirkin, a frustrated Juilliard student who had written to him for help.
"I was the kid who had always sat last-chair viola," said Mr. Mirkin, whose bow bounced from audition nerves. Two years later, he won a spot in the New York Philharmonic, where he has played for 22 years. "I never would have had a career in music without Inderal," said Mr. Mirkin, who, an hour before his tryout, took 10 milligrams.
For the last two decades, such use of beta blockers has generally met with approval from the medical establishment. "Stage fright is a very specific and time-limited type of problem," said Michael Craig Miller, the editor of The Harvard Medical Letter. Dr. Miller, who is also an amateur pianist, noted that beta blockers are inexpensive and relatively safe, and that they affect only physical, not cognitive, anxiety. "There's very little downside except whatever number you do on yourself about taking the drugs."
BUT now that the drugs have established themselves as a seemingly permanent part of the classical music world, some musicians and physicians are beginning to question the acceptability, safety, efficacy and ethics of using them. One concern is that many musicians use beta blockers without proper medical supervision. The 1987 survey of orchestra musicians revealed that 70 percent of musicians taking beta blockers got them from friends, not physicians. Mr. Mirkin, the Philharmonic violist, first obtained Inderal from his father, who took it for angina. Others buy it while touring countries where they are sold over the counter.
Stephen J. Gottlieb, a professor of medicine who published a study on the effects of beta blockers in The New England Journal of Medicine in 1998, says beta blockers should be obtained only after a medical examination, since people with asthma or heart disease could develop problems like shortness of breath or a slowing of the heart rate. "One-time use of low doses of beta blockers should be safe in healthy people," Dr. Gottlieb said, adding that the fatigue, hallucinations, tingling and vivid dreams listed as side effects in Physicians' Desk Reference would be unusual in those using Inderal only occasionally. The risks are far more serious for those who use beta blockers consistently and take up to 700 milligrams of Inderal a day. Musicians typically take 5 to 20 milligrams in isolated doses.
But some performers object to beta blockers on musical rather than medical grounds. "If you have to take a drug to do your job, then go get another job," said Sara Sant'Ambrogio, who plays cello in the Eroica Trio. Chemically assisted performances can be soulless and inauthentic, say detractors like Barry Green, the author of "The Inner Game of Music," and Don Greene, a former Olympic diving coach who teaches Juilliard students to overcome their stage fight naturally. The sound may be technically correct, but it's somewhat deadened, both men say. Angella Ahn, a violinist and a member of the Ahn Trio, remembers that fellow students at Juilliard who took beta blockers "lost a little bit of the intensity," she said. Ms. Ahn doesn't use the drugs, she said: "I want to be there 100 percent."
Indeed, the high stakes involved in live performance are part of what makes it so thrilling, for both performers and audiences. A little onstage anxiety may be a good thing: one function of adrenaline is to provide extra energy in a threatening or challenging situation, and that energy can be harnessed to produce a particularly exciting musical performance. Performance anxiety tends to push musicians to rehearse more and to confront their anxieties about their work; beta blockers mask these musical and emotional obstacles.
Some musicians are also grappling with the ethics of better performing through chemistry. In auditions, which are even more nerve-racking than regular performances, do those who avail themselves of the drug have a better chance of success than those who do not? Should drug testing apply to performers, as it does to some athletes and to job applicants at some companies?
"If you look at the logic of why we ban drugs in sport, the same should apply to music auditions," said Charles Yesalis, a professor at Pennsylvania State University who studies performance-enhancing drugs. But the issue receives little attention because, unlike athletes, classical musicians are seldom called on to represent big business ventures. "If Nike offered musicians ad contracts," Dr. Yesalis said, "more people would pay attention."
Speaking from the Athens Olympics in August, Steven Ungerleider, a sports psychologist and the author of "Faust's Gold," said that beta-blocking medications are prohibited for some events, like riflery, in which competitors use the drug to slow the pulse so that they can fire between heartbeats to avoid a jolt. The drugs are banned in a number of other sports, including motorcycling, bobsledding and freestyle snowboarding.
But Dr. Miller, the Harvard physician, points out that beta blockers differ significantly from steroids, which use testosterone to increase muscle mass, strength and speed. Inderal enables rather than enhances, by removing debilitating physical symptoms; it cannot improve tone, technique or musicianship, or compensate for inadequate preparation.
As Ms. McClain's firing demonstrates, the use of beta blockers by students is a particularly delicate issue. Those who openly use the drugs believe they have a responsibility to mention them to students suffering from severe stage fright.
"If I'm looking out for the welfare of my students, I cannot in good conscience not tell them about beta blockers," said Ms. McClain, adding that she would be more careful about how she represented the information in the future.
Some teachers believe that coping with performance anxiety is an essential part of a classical music education and that early use of beta blockers deprives students of the chance to confront their stage fright. Robert Barris, a bassoonist and a co-chairman of the music performance studies faculty at Northwestern University, encourages students to address the roots of their anxieties while avoiding psychological dependence on chemicals. Unlike previous generations of musicians, these students can draw on a rich array of nonchemical treatment options. The new field of performing-arts medicine includes some 20 centers across the country, many of which treat stage fright with therapies that range from Inderal to more holistic approaches like hypnosis, yoga and aerobic exercise.
But several musicians interviewed for this article expressed impatience with these treatments, which can seem slow and uncertain compared with the instant gratification and convenience offered by the beta blockers. "Holistic solutions take work and time to be effective, whereas Inderal is a quick fix," Mr. Barris confirmed. As it happens, he takes Inderal by prescription for a heart ailment, and he said that he works to combat any soporific effects the drug might have on his musicianship by putting extra energy into his concerts. "No one wants to listen to a secure, accurate but disconnected performance," he added.
Jim Walker, a former principal flutist of the Los Angeles Philharmonic who has recorded more than 400 movie soundtracks, says that preparation is the best medicine. Still, he describes himself as an Inderal advocate, with the caveat that the drug be approved by a physician. Some of his best students at the University of Southern California, he said, are too nervous to deliver a representation of how well they really play and might stand to benefit from beta blockers.
"It's absolutely legitimate to recommend Inderal to a student who's unable to perform because of nerves," he added. "If I'd never heard the story about Ruth Ann McClain, I'd be far more blatant in recommending it."
Blair Tindall, a professional oboist, is writing "Mozart in the Jungle" for Grove/Atlantic Press. Elaine Aradillas contributed reporting for this article.
Correction: October 24, 2004, Sunday An article on Oct. 17 about the use of beta blockers by classical musicians to combat stage fright misidentified the journal edited by Dr. Michael Craig Miller, who said there was "very little downside" to their use. It is The Harvard Mental Health Letter, not the Harvard Medical Letter.
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First of all, although plenty of musicians use beta-blockers on occasion (in a classic 1986 study, about 20% of professional orchestral players admitted to occasional use), be aware that these are prescription drugs primarily given to people with heart conditions.How many musicians take beta-blockers? ›
A 1987 study showed that 27 per cent of US professional orchestral musicians were taking beta-blockers occasionally to control their nerves.Do musicians use beta-blockers? ›
Beta blockers have been common in classical music since the 1970s. Originally prescribed to treat high blood pressure, they became performance enablers when it became clear that Inderal (the brand name) controlled stage fright.Why do actors take beta-blockers? ›
Beta blockers may give performing artists a temporary sense of comfort, but comfort should not be the goal. The goal is to win the audition. That takes a lot of energy, over several rounds. Beta blockers may get you through the first round, or even past the semifinals, but they won't help you to win the audition.Why beta-blockers are not recommended? ›
Side effects commonly reported by people taking beta blockers include: feeling tired, dizzy or lightheaded (these can be signs of a slow heart rate) cold fingers or toes (beta blockers may affect the blood supply to your hands and feet) difficulties sleeping or nightmares.Do beta-blockers alter the brain? ›
For years, beta-blockers have been known to cause central nervous system (CNS) side effects, such as psychiatric conditions, bizarre and vivid dreams, sleep disturbances, delirium, psychosis, and visual hallucinations .Can you stay on beta blockers for life? ›
How long can I stay on beta-blockers? You can use beta-blockers for extended periods. In some cases, especially for adults over 65, it's possible to use them for years or indefinitely.Can you stay on beta blockers indefinitely? ›
Beta blocker therapy is recommended after emergency heart attack treatment to reduce your risk of irregular heart rhythms, chest pain or another heart attack. In the past, many people have taken beta blockers for years — often indefinitely — after a heart attack.Do beta blockers improve performance? ›
Nevertheless, the ability to perform athletic events requiring high levels of motor control under emotional stress but not high levels of aerobic or anaerobic energy release, is probably increased during beta-blockade.What do performers take for anxiety? ›
Propranolol is sometimes used off-label to help with certain kinds of anxiety, such as performance anxiety. Propranolol can help with physical performance anxiety symptoms, including dry mouth, nausea, fast pulse, or shaky hands. It's FDA-approved to treat many other conditions, such as high blood pressure and tremors.
Beta blockers reduce sympathetic effects, such as increases in heart rate and blood pressure, which often are heightened during athletic competition. WADA explicitly prohibits beta blockers in sports that are reliant on stability of the extremities, such as archery, racing, billiards, darts, golf, shooting and fishing.What do performers take for nerves? ›
Originally designed to treat heart conditions, propranolol is also a highly effective medication prescribed off-label for treating the physical symptoms of social and performance anxiety. Below, we've explained what propranolol is, how it works and how you can use it to manage most performance anxiety symptoms.Do beta-blockers dull emotions? ›
Conclusions: These results provide updated experimental evidence that beta-adrenergic blockade attenuates negative, high arousal emotions in response to a psychosocial stressor while also blunting sympathetic nervous system reactivity.Is there a natural beta blocker? ›
Fish, garlic, berries, and certain vitamins and amino acids are all natural sources of beta-blockers. Doctors usually prescribe beta-blockers to treat cardiovascular conditions such as angina and hypertension, which is also known as high blood pressure.Do beta-blockers increase testosterone? ›
Significant drug effects on both total and free testosterone were found during treatment with all four beta-blockers, although it appeared that the nonselective drugs (pindolol, propranolol) were associated with the greatest reduction in testosterone.What is a good replacement for beta-blockers? ›
Other drug classes used to treat similar conditions as beta-blockers include angiontenin-converting enzyme inhibitors, (ACEIs), angiotensin II receptor blockers (ARBs), aldosterone antagonists, calcium channel blockers (CCBs), vasodilators, diuretics, and medications which control the heart rate or heart rhythm.Can beta-blockers damage a healthy heart? ›
Shill explains that if taken incorrectly they could actually weaken the heart. When not taken as prescribed, they can do more harm than good. Beta blockers can cause a dangerously low heart rate called bradycardia which can lead to low blood pressure.Which is the safest beta blocker? ›
Based on research studies, there are three beta blockers that are best for heart failure: carvedilol, metoprolol succinate (the long-acting form of metoprolol), and bisoprolol. These beta blockers have been shown to lower your risk of dying from heart failure complications.What organ does a beta-blocker affect? ›
Beta blockers cause the heart to beat more slowly and with less force, which lowers blood pressure. Beta blockers also help widen veins and arteries to improve blood flow.What are the long term side effects of beta-blockers? ›
Long-term side effects of beta-blockers may include disorientation, short-term memory loss, emotional lability (rapid, extreme changes in mood), inability to concentrate or think clearly, and decreased performance on neuropsychological tests used to measure a psychological function.
Beta blockers decrease the rate at which blood is delivered to the fingers and toes, but more importantly, a decrease in the volume of blood results in cold hands. Cold hands are a common complaint of patients on beta blockers.Can you drink alcohol if you are on beta-blockers? ›
It is typically advised by doctors that you don't drink alcohol while taking beta-blockers. This is because beta-blockers are a blood pressure medication predominantly prescribed to people suffering from high blood pressure. Alcohol consumption can cause an individual's blood pressure to spike and ultimately lower.Can you get addicted to beta-blockers? ›
Unlike traditional anxiety medications, beta blockers are not addictive. Propranolol and the like do not cause drug dependency (or withdrawal symptoms when you stop taking them) and are safe to take occasionally over a long period of time.Why do beta-blockers increase stroke risk? ›
The most likely explanation for the increase in deaths and stroke among those taking beta blockers was that these patients could go into shock if their blood pressure were too low, a not uncommon complication of surgery, Devereaux said.What is the most commonly prescribed beta blocker? ›
What is the most prescribed beta blocker? The most prescribed beta-blocker medication in 2021 was metoprolol succinate with more than 18 million prescriptions. The drug is an extended-release medication that can be taken once a day. Metoprolol tartrate has the second most prescriptions at around 11 million.Why do beta blockers cause fatigue? ›
Answer: Well, a lot of patients do not like taking beta blockers, because the way it works is it drops your heart rate, and if you drop your heart rate, the amount of blood that the heart is pumping forward may also drop, creating symptoms of fatigue, impotence, drowsiness, lethargy, et cetera.Can beta blockers cause heart failure? ›
Major cardiac effects caused by beta blockade include the precipitation or worsening of congestive heart failure, and significant negative chronotropy.What type of athlete would use beta-blockers? ›
Because beta-blockers lower the heart rate and have a strongly relaxing effect, and also because they prevent muscle trembling, abuse for doping purposes occurs in sports that require particular accuracy and concentration, e.g. in shooting, archery, darts, golf and snooker. In addition, beta-blockers reduce anxiety.What athletes have been caught using beta-blockers? ›
Ravi Kumar was tested positive for a beta-blocker after returning from the Munich World Cup. Shooter Ravi Kumar joined the list of top Indian athletes caught in the dope net after he tested positive for a beta-blocker and is provisionally suspended.Why do athletes take propranolol? ›
Propranolol is a beta-blocker, so it blocks the action of adrenaline. Adrenaline is implicated in a number of effects on the body—high blood pressure and a fast heart beat, for example—so by blocking it, propranolol lowers blood pressure, and heart rate.
ED drugs like sildenafil (Viagra®, generic Viagra), tadalafil (Cialis®), and avanafil (Stendra®) can also be used in sexual performance anxiety treatment as a way to provide more confidence for men with sexual performance concerns.How do high performers deal with stress? ›
- Use a meeting agenda.
- Develop healthy response methods.
- Seek support with one-on-one meetings.
- Recharge regularly.
- Maintain healthy boundaries.
- Avoid multitasking.
- Track additional time demands.
- Take advantage of your community.
Focus on Your Breathing
Whenever you feel nervous, focus on your breath and the rising and falling of your belly. This has a calming effect that will eliminate the nervousness and let you focus on your singing. It also helps to do breathing exercises before you get on the stage.
Types of performance enhancing drugs. Among the most popular PEDs are anabolic steroids, human growth hormone, erythropoietin (EPO), beta-blockers, stimulants and diuretics to name just a few. While drugs such as these get a lot of publicity, they are perhaps not well understood. What do they do?Why do archers use beta blockers? ›
Although the use of doping substances is not common in sports requiring fine motor movements, some archers may use such drugs to reduce HR, diminish anxiety and reduce body sway during shooting based on the findings from previous studies.Are antihistamines banned in sport? ›
Antihistamines are not prohibited; however, an important principle of prescribing to athletes is that no medication should adversely affect the athlete's performance.What is the best medication for stage fright? ›
May reduce some peripheral symptoms of anxiety, such as tachycardia and sweating, and general tension, can help control symptoms of stage fright and public-speaking fears, has few side effects.
But not just for amateurs. Believe it or not, some of the most famous professional singers, actors, and entertainers get terrible stage fright. Anxiety and nerves are completely natural. In fact, they often help give you the right pump of adrenaline before stepping out on stage.How common is hair loss with propranolol? ›
Propranolol is one of several beta-blockers that can cause hair loss, however, given the widespread clinical usage, cases have been rare . The suggested mechanism is a direct toxic effect on hair follicles . The hair loss from propranolol is not permanent and is typically a result of telogen effluvium.Can beta blockers change your personality? ›
They are a common treatment for cardiovascular diseases, including heart failure, arrhythmias, chest pains and high blood pressure. Researchers have suspected beta-blockers of having negative psychological side effects, including depression, anxiety, drowsiness, insomnia, hallucinations and nightmares.
In healthy humans, propranolol has been found to impair the consolidation of emotional items memory (Cahill et al., 1994; van Stegeren et al., 2005), and of fear memory in a contextual fear conditioning test (Grillon et al., 2004).Do beta blockers block dopamine? ›
These results indicate that propranolol administration may cause a potentiation of norepinephrine activity specifically at alpha receptors, due to concurrent beta receptor blockade and inhibition of norepinephrine reuptake and a decrease in dopamine activity at dopaminergic receptor sites due to an inhibition of ...Do bananas work as beta-blockers? ›
Bananas are a great pre-presentation snack because they are natural beta-blockers. Beta-blockers are medications that “block epinephrine and norepinephrine from attaching to the beta receptors on the nerves of your blood vessels and heart.” What does all that mean? Well, it means bananas can help lessen anxiety.What is a beta blocker Kardashians use? ›
Khloe Kardashian Says She Takes Kris' Beta Blockers For Her Anxiety—Here's What The Meds Do, And If It's Safe. According to Dr. Dimitriu, there are a few reasons why someone might be taking beta-blockers.What happens if a man takes testosterone blockers? ›
Testosterone blockers (i.e. Spironolactone) can increase the risk of developing high levels of potassium in the body and low blood pressure. High potassium can be life-threatening and can cause muscle weakness, paralysis and abnormal heart rates. Periodic hormone and potassium level checks are important.What drugs increase testosterone production? ›
Fluoxymesterone is used to treat symptoms of low testosterone in adult men who have hypogonadism (a condition in which the body does not produce enough natural testosterone).Which drugs cause erectile dysfunction? ›
Beta‐blockers are one kind of drug which can used for symptomatic relief of angina and prevention of ischaemic events based on the function of reducing myocardial oxygen demand by decreasing heart rate and myocardial contractility.Do beta-blockers improve performance? ›
Nevertheless, the ability to perform athletic events requiring high levels of motor control under emotional stress but not high levels of aerobic or anaerobic energy release, is probably increased during beta-blockade.Do beta-blockers affect performance? ›
Sheps, M.D. Beta blockers slow the heart rate, which can prevent the increase in heart rate that typically occurs with exercise. This means that it might not be possible for you to reach your target heart rate — the number of heartbeats per minute you typically aim for to ensure you're exercising hard enough.
For people who experience situational or performance-related anxiety, beta-blockers (a medication commonly prescribed for heart conditions) can provide some relief.What is the first drug of choice for angina? ›
Nitrates or beta blockers are usually preferred for initial treatment of angina, and calcium channel blockers may be added if needed. The number and type of medications used are often tailored to how frequently angina occurs in an average week.How can I reverse angina naturally? ›
- Stop smoking. Smoking cigarettes is detrimental to cardiovascular health and efforts should be made to stop.
- Work towards a healthier body weight. ...
- Consume omega-3 fats (EPA+DHA) ...
- Eat more plants. ...
- Reduce intake of bad fats and sugar. ...
- Exercise regularly.
The nitrate-induced acceleration of heart rate should be compensated by the addition of beta-blockers or heart rate-decreasing calcium channel blockers. Therefore, the combination of nitrates with heart-rate-increasing calcium channel blockers, such as nifedipine, should be avoided.Do beta-blockers increase energy? ›
The anti-adrenaline effect of beta-blockers — the very quality that makes them valuable for treating heart failure — can make patients feel tired. Most patients do not experience any side effects.How long should you be on beta-blockers? ›
Guidelines recommend beta blocker therapy for three years, but that may not be necessary. Beta blockers work by blocking the effects of the hormone epinephrine, also called adrenaline. Taking beta blockers reduces your heart rate and blood pressure. This eases the workload on your heart and improves blood flow.What do doctors prescribe for performance anxiety? ›
Propranolol is sometimes used off-label to help with certain kinds of anxiety, such as performance anxiety. Propranolol can help with physical performance anxiety symptoms, including dry mouth, nausea, fast pulse, or shaky hands. It's FDA-approved to treat many other conditions, such as high blood pressure and tremors.What should you not take with gabapentin? ›
- strong painkillers, such as morphine – these can make you very tired and dizzy when you start taking gabapentin.
- antidepressants, such as amitriptyline or fluoxetine.
- antipsychotic medicines for mental health problems like schizophrenia or bipolar disorder.
Fish, garlic, berries, and certain vitamins and amino acids are all natural sources of beta-blockers. Doctors usually prescribe beta-blockers to treat cardiovascular conditions such as angina and hypertension, which is also known as high blood pressure.