A PRESCRIPTION FOR SUCCESS
(This article was originally published in theHarp Column July/August 2001 issue, vol. 9, no.1)
Carl Swanson was tired of suffering from debilitating performance anxiety behind the harp. He and his doctor decided there was something they could do. Could their solution work for you?
By Carl Swanson
With Dr. Abraham Saltzman, M.D.



    Performance anxiety. Stage freight. Call it whatever you want; we all get nervous. But being the individuals that we are, we all get nervous in different ways and to different degrees.

    This phenomenon is not new. Chopin once referred to another pianist friend of his as “The greatest pianist in the world.” But then he added, ”But you will never hear him, because he cannot play in public.” Two famous performers who were incapacitated by performance anxiety were Vladimir Horowitz and Lawrence Olivier. Horowitz retired twice from public performing—each time for more than 10 years—because of his inability to control his nerves. Olivier, in an interview on 60 Minutes, said that he had reached a point well into middle age and many years into a glorious stage career when he simply could no longer go out on stage. For the next 15 years or so he focused on a movie career, because making movies didn’t bother him. Late in his career he discovered the drugs that could control the nerves, and he returned to the stage.

    The universal enemy to all performers is adrenaline, the hormone of the adrenal gland, and the symptoms it creates under the pressure of performance. Those of us who are badly affected by stage freight know that the audience is simply the catalyst that sets things in motion. It is not the audience we fear, it’s the adrenaline.

    The list of things that happen to a performer under the spell of adrenaline is long and varied. The most common are sweating, cold or shaking hands, loss of muscle memory, scattered or disorganized thoughts, or the inability to focus. Just when we need control the most, it seems to fly out the window.

    I am always amazed by performers who can maintain control under the most stressful conditions: music competitions, senior recitals, jury exams, etc. But there are many of us for whom the rush of adrenaline is just so strong that our performance is seriously degraded. Thankfully, there are now drugs that, when taken correctly, can have a miraculous effect on controlling even the worst case of nerves.

    WHAT ARE THE DRUGS THAT ARE USED FOR PERFORMANCE ANXIETY?

    The group of drugs that performers such as actors, dancers, and musicians use are called beta blockers, and were originally developed for people with various heart problems, as well as hypertension, migraine, hyperthyroidism, and essential tremor. In those applications, their purpose is to slow the heart rate and lower blood pressure. A beta blocker does this by blocking the receptors for adrenaline. People who have heart problems may take a beta blocker several times a day. The original beta blocker medication was called Inderol, and that is the name people are still most familiar with. The patent ran out many years ago, and a generic version called Propranolol is the one most often prescribed today. There is a second group of drugs called alpha blockers that can also be helpful to performers. Alpha blockers were developed for use in people with high blood pressure, and they lower the blood pressure by dilating the blood vessels slightly.

    DO YOU NEED DRUG INTERVENTION FOR YOUR PERFORMANCE ANXIETY?

    That depends. The question is not whether or not you get nervous, but rather how seriously your performance is degraded by the adrenaline rush you get. Does your performance fall apart? Does missing one note turn into a major crash and burn? Does your performance sound nervous? Do you feel like you are always tottering on the edge of disaster as you make your way through the performance? Are you unable to really get into the piece in performance because you are so concerned with just making it to the end? If you were to rate your very best ability to play a given piece (relaxed, alone, warmed up in your living room) as a ten, what is the grade you would give the same piece in performance? Nine; seven; three; one? You need to ask yourself these questions and answer them honestly before deciding if you need drug intervention.

    The problem with performance anxiety, of course, is that if you have difficulty performing, it only gets worse with experience. That’s because you are building on your previous track record. Each new performance is approached with greater and greater anxiety. If any of the questions in the previous paragraph apply to you, drug therapy could help you turn things around.

    WHAT DOES IT FEEL LIKE WHEN YOU TAKE A BETA BLOCKER?

    Beta blockers are not tranquilizers. They are not muscle relaxants. And they are not mood elevators. They simply block the effectiveness of the adrenaline that is sent into your system under stress. There is no “high.” There is no drowsiness. There is no physical sensation at all that you have taken them. They are not habit forming, and if you use them for performance, you take them only when you perform.

    There are two important issues you must address to gain the performance benefit from taking a beta blocker: how much medication you need to take, and how far in advance of the beginning of the performance you need to take it. If you get either of these issues wrong, you will get little or no benefit from the drug. I must emphasize here that getting the timing right is as important as the size of the dose. Each person’s metabolism is different, which means that the drug is absorbed into the system, and removed again, at different rates for different people.

    SO WHERE DO YOU START?

    Start by identifying the situation or situations that cause you performance anxiety. Most people I talk with have very specific situations that send them into orbit. One harpist I know said, “Playing for a bunch of people in my living room doesn’t bother me at all. It’s walking out on stage that does it.” For someone else it may be orchestra playing, but not chamber music. Another person may not react to background playing, but fall apart during solo recitals. Try to identify as specifically as possible what it is that you are trying to improve with drug intervention.

    In order for a beta blocker to help you, you will have to experiment to find the dose and the timing that work best for you. Your goal is to figure out the smallest dose that does what you want it to do, and to time it so that you get the maximum benefit.
Beta blockers are prescription drugs, and you must talk to your doctor before taking them. Do not borrow a pill from a friend. If you have a slow heart rate, or have asthma, for example, beta blockers may not be right for you, and could be dangerous. Secondly, without figuring out the dosage and timing that works for you, they probably won’t be very effective, as you will see in a moment.

    Unless you have a doctor who is familiar with the use of these drugs for performance, he or she will be thinking of them in terms of heart medication. Your doctor will probably tell you to take your resting heart rate, try a dose that he suggests, and take your heart rate again to see how much that dose slows your heart. But that doesn’t relate very well to your situation since you are not trying to slow your resting heart rate. You are trying to offset the effect of increased adrenaline at the time of performance. The minor effect of one dose of the drug on your heart rate is of secondary importance to you as a performer; it is the other things that adrenaline does to you that you want to eliminate, and your doctor will not know how to measure that. It may turn out that you only need a very small dose of a beta blocker to accomplish what you want, and that small dose may have no effect on your heart rate at all.

    Find a way of recreating on a small scale the type of situation that makes you nervous. It may simply be playing for a few people in your living room, or it may involve playing for a class or church group. If playing for a few people in your living room will do it, then invite some people over and let them know up front what you are doing. Take the medication you and your doctor have decided to try about one hour in advance of the first notes. Try playing your piece. If you feel any nervousness at all, stop, tell your friends that you want to wait a half hour before trying it again. Then serve them dessert and coffee!
   
    At the one-and-a-half hour mark, try the same thing again. Are you calmer now? Are you still aware of your nerves? If you are still feeling nervous, stop again, serve more dessert and coffee, and wait for the two-hour mark. This is the only way you are going to find out when you have maximum benefit. Two hours is most likely the longest you will have to wait, and if you are still nervous then, you will probably need to increase the dose. When you finally get the dose and timing correct, you should not feel even the smallest hint of nervousness. All of the symptoms of performance anxiety that you have identified for yourself should be completely gone.
   
    How do you find a physician who can help, and what do you tell him?

    Start with your personal physician. After all, he knows you best. Show him this article, and tell him how it relates to your situation. You may have to educate your doctor about this.

    You will be looking for a short acting beta blocker, either Inderol or Propranolol. There are other drugs in this group, but most are long acting(12 to 24 hours) and are not appropriate for performance. The short acting varieties wear off in 4 to 6 hours.


    The standard dose of Propranolol for performers is 20 milligrams. I know people who take less(as little as 5 mg) and some who take more(30mg or 40mg). Most performers I have talked to take it about an hour before performance, but that doesn’t work for everyone. It can take up to 2 hours to fully kick in. By the way, if you take, or change to another brand of beta blocker, then you will have to start all over again figuring out the dose and timing. In other words, 30mg of Propranolol is not the same as 30mg of Coreg for example. If you have a problem with cold hands which can be improved by an Alpha blocker, you will probably have to take 50, 100, or 150 mg of Labetalol along with your dose of Propranolol. But if you change to some other brand of alpha blocker, again, you will have to start from scratch to figure out how much will work for you.

    If you are an accomplished musician, you’ve no doubt invested hours of time perfecting your technique and many dollars on a fine instrument. But if you cannot give the kind of performance you know is within you because your nerves get in the way, you owe it to yourself to investigate the possibility of drug therapy. If you are bothered by performance anxiety, but are still a little unsure if drug therapy is for you, keep reading for an example of how using beta blockers has changed my life as a musician.

    A PERSONAL PERSPECTIVE     Could Beta Blockers work for you? Here is the story of how our author, Carl Swanson,     decided to try beta blockers as an aid to helping him overcome his performance anxiety.

    I react worse to performance nerves than anybody I know. I always have. I tell people that I must crank out enough adrenaline to kill a horse. Every form of performing makes me extremely nervous. One person in the living room or 400 in a concert hall are the same to me. This reaction runs on my mother’s side of the family. She was the same way, and I have a maternal cousin who has the same problem. So I think it must be genetic.

    It wasn’t always as bad as this. Back in my student days, most non-solo situations( orchestra, background music, even chamber music)didn’t bother me that much. The really bad nerves back then were limited to solo playing. But my career went in a direction away from performing. I didn’t do this to avoid performing, but I didn’t miss it when I stopped. And so as a harpist, I hibernated for many years and completely lost any comfort level I had had for playing in public.

    But five years ago I started playing again. At first it was only for my own pleasure, but several harpists in Boston asked me to play for the local American Harp Society (AHS) chapter, and I felt it was time to overcome the obstacle of performance anxiety once and for all.

    I had used beta blockers off and on for public speaking; giving lectures at AHS conferences, for example, and to introduce Marie-Claire Jamet at her wonderful opening recital at the Boston conference in 1994. But the few times I had used them for playing, they really didn’t work very well. I had been told by a musician who is also a nurse that they go through your system very quickly; he had advised me to take them no more than an hour before performance time. But that hadn’t worked for me, so I felt I needed to experiment with both the dosage and the timing.

    I identified three issues that I was trying to correct with the medication. First, the adrenaline rush I get fragments my muscle memory. What this means is that under the stress of performance, everything feels uncomfortable and unfamiliar: the patterns that make up the piece I’m playing and which I practiced so hard to learn seem to disappear. Throughout the performance, I feel like I have no idea where I am and what is coming up next. No amount of practicing can offset or overcome this fragmentation caused by the adrenaline. Second, the adrenaline destroys my ability to concentrate. I am hyper aware of everything around me, and my brain is racing in overdrive, destroying my concentration and ability to focus on what I am doing. And third, my hands are glacially cold to the point of being stiff. Warming up will not fix this, since it is caused by the adrenaline constricting the blood vessels in my hands.

    These were the issues, and I decided to find out if drug intervention could prevent these things from happening, or at least minimize them. I invited six people over to my home for dinner and told them that I would be playing for about 35 minutes first. On the appointed night, I took a dose that my doctor and I had decided on, at what I thought would be the one-and-a-half hour mark. But by the time everyone showed up and I was ready to start playing, two hours had passed since I had taken the medication.

    The experience was astonishing! I felt calm and comfortable. All of my muscle memory was there, and I felt, for the first time in my life, like I had good control. My concentration was amazing. Within 15 seconds of starting each piece, I was totally focused. One problem remained however: My hands were still freezing and stiff. The faster pieces didn’t go as well as I wanted because of that.

    I went back to my doctor and discussed the results of the first experiment with her. I already had a repeat performance scheduled for two weeks later, and asked her what I should do now. Her suggestion to increase the dose slightly was, I learned many months later, the worst advice she could have given me. The next performance, again in my living room for another group of friends, was awful. I was in the middle of a bad cold and should have cancelled the whole evening, but I played anyway. My hands were just as cold and stiff as before, and in addition, I had several bad memory lapses. (I should mention here that there is some hearsay evidence that too high a dose of beta blocker may cause memory lapses, for reasons that will become apparent in a moment. But back to my story.)

    Several weeks later I played two pieces for the local harp chapter and at a musical soiree at the home of a friend. I went back to the original dose and two-hour timing, and everything was fine: great muscle memory, great concentration, no memory lapses. But I still had freezing hands. I had even tried warming them with a heating pad while I waited to play, but it didn’t work.

    It was several months later, on a visit to my elderly Aunt Margaret, that I stumbled on the solution. She had a big fat book that explained prescription drugs in lay terms. I looked up beta blockers and discovered that they have one unfortunate side effect. Just like adrenaline itself, beta blockers, in higher doses, can constrict the blood vessels in the skin of the extremities, causing cold hands and feet. Heart patients who take beta blockers daily frequently have to take an alpha blocker as well to counteract that one side effect. So I had found the answer to my problem. I was already taking a fairly high dose of Propranolol, and by taking an even higher dose I was making my hands colder. If the medication was constricting the blood vessels in my hands, then maybe it was also constricting them in my brain, just enough to bring on memory problems.

    When I got home I talked to my doctor about this and requested an alpha blocker. She gave me Labetalol. I had to experiment some more to get the dose right, but the results have been truly miraculous. Last March I gave four full solo concerts in three weeks. Lest you think I am making a mountain out of a mole hill, the program (played entirely from memory) included: The Allemand in B-flat, by Bach, the “Serenade,” by Parish-Alvars, “Introduction, Cadenza, and Rondo,” also by Parish-Alvars, “Une chatelaine en sa tour,” by Faure, three movements from the “Mother Goose Suite,” by Ravel, and Etude no. 7, by Posse, as well as several pieces by Tournier. I took my usual dose of both the Beta blocker (Propranolol) and the alpha blocker (Labetalol) together, two hours in advance of the first notes. I had all of my muscle memory, ferocious concentration, and my hands were toasty warm and nimble. And there were no memory problems. I was very, very happy with all four performances, and can say that there was no degrading at all of the pieces from performance nerves. It occurred to me after one of these concerts that this was the first time in my life that anyone had heard how I could really play.
   
    I now know the precise dose of the two different drugs I have to take exactly two hours ahead of the performance, and I know exactly how I will feel and perform. I have taken my resting heart rate numerous times, and have taken it moments before I had to walk out on stage. The rate was exactly the same for both situations. As far as the alpha blocker is concerned, when someone with normal blood pressure takes an alpha blocker, it will dilate the blood vessels without changing the blood pressure significantly.
 
  The benefits of using these drugs correctly go beyond the actual performance. When I started performing again after so many years, even though I was now using the drugs, I had a lot of anxiety in the days leading up to the first performance. But with each successful performance the anxiety was less and less, until finally there was none at all. This past fall I performed the Debussy “Danses” with orchestra. I remember sitting behind stage waiting for the piece before mine to finish. I was calm and happy, eagerly looking forward to the privilege of playing this lovely piece one more time with the orchestra, and sharing the experience with the audience. I thought to myself as I sat there, ”Isn’t this what making music is really all about?”


Published: Harp Column vol. 9, issue 1 july/august 2001 PAGE 1 - PAGE 1 -