Imagine sitting in a concert hall listening to the melodious strains of a Brahms symphony. It only takes a single wrong note for the entire performance to quickly turn sour. The very fragility of performances places an incredible amount of pressure on musicians to constantly perform at their absolute best, and this pressure often causes performance anxiety. An increasing number of musicians have been fighting this anxiety with the help of a type of medication known as beta blockers, but this so-called cure for stage fright has been met with much controversy.
Beta blockers are a class of prescription drugs that block the binding catcholamines, which are produced and secreted into the bloodstream by the adrenal gland, to adrenergic located on the surface of cells in the heart, lung, arteries, brain, and uterus .There are three main catecholamines present in tissues and organs throughout the body: epinephrine (commonly known as adrenaline), norepinephrine, and dopamine, and two different types of adrenergic receptors, the alpha-receptors and the beta-receptors. Beta-receptors are located in the cells distributed throughout muscle tissue and the heart’s conduction system, the lung airways, and the walls of blood vessels. The binding of adrenaline to these receptors generally triggers an accelerated heart rate, forceful contractions of heart muscles, increased blood flow through the muscles, and bolstered air flow in the lungs . The anxiety caused by the fear of missing a note, or perhaps the pressure induced by the expectations of the audience, induces this physiological response that occurs in stage fright.
Beta blockers diminish the effects of adrenaline, and therefore stage fright, by slowing the nerve impulses traveling to the heart, reducing the amount of the work the heart must do. Because of this capability, beta blockers are usually prescribed as treatment for cardiovascular disorders including heart attacks, heart failure, high blood pressure, hypertension, and cardiac arrhythmias [1,2].
The effectiveness of beta blockers in helping patients who suffer from cardiovascular aliments has been proven and celebrated, but classical musicians have also embraced their use. Beta blockers decrease tremors and other physiological accompaniments of stage fright such as sweaty palms and sudden feelings of dehydration. It is easy to understand therefore why beta blockers can be so valuable for musicians who must perform perfectly in front of audiences of thousands; for many of them, a single slip up may cost them their jobs .
Although the FDA has never approved the usage of beta blockers to reduce performance anxiety, a study conducted in 1987 by the International Conference of Symphony Orchestra Musicians (ICOSM) found that 27 percent of its musicians used them. A New York Times article reported that by 2004 this percentage had become much higher, describing the use of these drugs among classical musicians as “nearly ubiquitous .”
The beginnings of beta blocker usage for combating stage fright are somewhat obscure, but it seems that vascular surgeon Charles Brantigan spurred their use amongst musicians. He researched the impact of the beta blocker Inderal on musicians in the late 1970’s. Replicating performance conditions in studies held at the Juilliard School in New York City and the Eastman School in Rochester, he measured the pulse and blood pressure of a selected group of students. Also, he recruited experts to judge the quality of performance. His studies determined that the drug improved all three test conditions, lowering the heart rates and blood pressures of the performers, while leading to performances that the judges deemed superior to those performed in the placebo trial. Upon the publication of the results of Brantigan’s study, multitudes of musicians were persuaded to try the drug to calm their nerves during performances. However, both the musical and scientific communities are divided over their opinions in regards to the safety, efficacy, and ethical acceptability of beta blockers.
The use of beta blockers for anxiety related purposes has been met with general approval from medical establishments for the past two decades. Dr. Michael Craig Miller, editor of The Harvard Health Letter, expressed approval of the drug in a New York Times article, noting its inexpensive and relatively safe qualities. Furthermore, several musicians endorse the use of beta blockers, believing that it can be necessary for some people to reach their full potential. Ruth McClain, a Memphis flutist who once suffered from enervating jitters when performing, claims she never looked back after first trying beta blockers . In 1980, Kenneth Mirkin, a Juilliard student frustrated with his audition nerves wrote to Brantigan, who sent him his findings. Before taking any medication, Mirkin’s bow would bounce from audition nerves as he tried to perform, but two years after writing to Brantigan, he won a spot in the New York Philharmonic. Merkin attributes the success of his audition to Inderal, and claims that he would never have had a career in music without it .
One important criticism is that many musicians use beta blockers illegally without proper medical supervision or approval. Of the 27 percent of musicians who admitted to using beta blockers in the 1987 ICSOM survey, 70 percent received the drugs from friends and not from doctors. Critics point out that improper use of beta blockers can lead to dizziness, light-headedness from drops in blood pressure, and even wheezing for those with asthma .
Some musicians complain that beta blockers make music technically flawless, but soulless. Angella Ahn, a violinist in the Ahn Trio, a classical piano trio composed of three sisters, claims that her Juilliard peers that took beta blockers would tend to lose a bit of their performance intensity . Joseph Silverstein, violin professor at the Curtis School of Music and former concertmaster of the Boston Symphony Orchestra, used beta blockers for a period of time after he had a heart attack, but then had his doctor take him off of them when he felt like he had “dumbed-down moments” in rehearsals and concerts on the drugs .
Most of the studies done on the efficacy of beta blockers for anxiety are dated, with the most recent ones conducted in the 1980’s, and contradictory. Studies such as one published in the Psychosomatic Medicine Journal in 1982 determined that although beta blockers lower heart rates, they do not significantly improve technical motor skills and performance. These findings, however, contradict the results of Brantigan’s study two years previous .
Perhaps the most controversial of issues surrounding the musical use of beta-blockers is its ethicality. The debate surrounding the use of beta blockers by musicians appears to some very similar to the debate surrounding the use of performance enhancing drugs in sports, but there has not been a strong enough objection to beta blocker use by musicians to result in any legal action. Charles Yeslais, a professor at Pennsylvania State University who studies performance-enhancing drugs, claims that the logic of banned drugs in sports applies to music auditions, but the issue receives little attention because classical musicians are not often called upon to represent large business ventures. In response to critics, musicians such as Hal Robinson, a former bass player with the National Symphony Orchestra, stated that beta blockers are not performance enhancers, but rather performance “enablers .” Physicians such as Dr. Miller from Harvard support them, pointing out that Inderal enables rather than enhances by removing debilitating physical symptoms but not improving tone or musicianship. Steroids, unlike beta blockers, actually improve inherent qualities such as muscle mass, strength, and speed through testosterone . Therefore, while some make the ethical argument that beta blockers are similar to musicians as steroids are to athletes, others claim that the two are ethically and practically very different.
There currently appears to be no general consensus amongst professional musicians regarding the appropriateness of using beta blockers to prevent performance anxiety. Advocates who have had positive experiences using beta blockers to improve performance quality are valid in supporting their use, yet critics are valid in pointing out that there is no conclusive scientific evidence proving their efficacy. As far as ethics are concerned, every musician is entitled to his or her own opinions regarding the integrity of using beta blockers. Whether or not a musician chooses to use beta blockers is a personal decision. After all, the end result, the music imparted by these artists, matters more than the means by which the music is played.
1. Bryce, Susan. “Beta Blockers as Treatment for Stage Fright.” Health Psychology Home Page, Vanderbilt University Psychology Department. 11/15/2005.
2. “Hyperthyroidism and Graves’ Disease: What are beta blockers?” Division of Endocrinology and Metabolism, Johns Hopkins University.
3. Lehrer, Paul. “A review of the approaches to the management of tension and stage fright in music performance.” Journal of Research in Music Education. 1987; 35(3):143-153.
4. Tindall, Blair. “Better playing through chemistry.” New York Times. Oct 17, 2004.
5. Watts, Vabren. “Beta-blockers used by musicians, athletes, students to enhance performance.” Philadelphia Inquirer. Aug 16, 2010.
6. Image Credit (Public Domain): Orchestra of the 18th Century.”Orchestra.” Wikimedia Commons. Last modified June 6, 2009.