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
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
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
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
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
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