Copyright Douglas Niedt. All Rights Reserved. This article may be reprinted, but please be considerate and give credit to Douglas Niedt.

In my opinion, there is no cure for stage fright. Others certainly will disagree. I admit I have not tried every cure out there but let’s face it—if someone had a cure, they would be very famous and very wealthy. No one would be suffering from this sometimes-debilitating malady.

But, there are ways to reduce and control performance anxiety. Unfortunately, I would estimate that 95% of the methods that claim to control stage fright do not work at all, work only for mild cases of stage fright, or only for a few individuals.

However, there is one very effective way to control stage fright or performance anxiety to enable you to give the best performances you have ever given. It will work for almost everyone. Here it is:

OKAY, THIS IS IT:
The One and Only Surefire, Quick, and Inexpensive Way to Control Stage Fright:

BETA BLOCKERS

Remember our earlier discussion of the brain’s fear-response programming? In a Ted-Ed video, Mikael Cho describes it this way (with some additions by me):

Humans are wired to worry about their reputation. Performing in public can threaten that. Before a performance you may think, “What if people think I’m awful? What if I am awful? What if I forget the music? They will think I’m a failure.”

That fear is a threat reaction from a primitive part of your brain that is very hard to control. It’s the fight-or-flight response, a self-protective process seen in a wide range of animals, most of which don’t give concerts.

To your conscious modern mind, you are giving a concert. To the rest of your brain, programmed with the “law of the jungle”, when you perceive the possible consequences of blowing a performance, it is time to run for your life. Or, fight to the death.

Your hypothalamus, common to all vertebrates, triggers the pituitary gland to secrete the hormone ACTH, making your adrenal glands shoot adrenaline into your blood. Your neck and back tense up, you slouch, your legs and hands shake as your muscles prepare for attack. You sweat, your blood pressure jumps. Your digestion shuts down to maximize the delivery of nutrients and oxygen to muscles and vital organs. You get dry mouth and butterflies. Your pupils dilate, so it’s hard to read anything up close. Your fingers may go out-of-focus on the fretboard. Your may have difficulty reading your music. But long-range vision is good. That’s how stage fright works.

The goal is to not let your hypothalamus convince your body it’s about to be lunch for a pack of predators. You cannot overcome stage fright. But you can adapt to stage fright. Remember, no matter how civilized and cultured you may seem, in part of your brain, you are still a wild animal. A profound, well-spoken wild animal who plays the classical guitar.

This is why dealing with stage fright is so difficult. We are attempting to shut down or control a part of us that is trying its best to save and protect us at a primordial level.

Finally, A Solution to Control Stage Fright or Performance Anxiety

The one thing that does work for most people in controlling performance anxiety is beta blockers. Beta blockers are pills. They are a class of prescribed drugs.

Beta blockers such as propranolol (often referred to by the brand name, Inderal) are used to treat everything from hypertension to heart attacks to tension headaches. They slow the heart rate, fight off stress hormones and restrain the amygdala, the part of the brain that controls emotional reactions.

That, in turn, calms the fight-or-flight reaction that can make hearts race, hands and fingers shake, palms go sweaty, and minds go blank. It can make a nervous musician calm in a performance, or make a difficult solo go more smoothly. A 10 or 20 milligram dose (a typical prescription for high blood pressure is 40 milligrams) will keep its taker calm for two to four hours.

In medical jargon, beta-blockers block beta-adrenergic substances, such as apinephrine (adrenaline) in the autonomic nervous system (involuntary nervous system). They slow down the heartbeat, decrease the force of the contractions of the heart muscles, and reduce blood vessel contraction in the heart, brain, as well as the rest of the body. They are prescribed by doctors to treat a wide variety of conditions.

For the musician, beta blockers stop the shaking of hands and fingers. Completely. Knowing you will have excellent motor control under the most stressful performance circumstances helps reduce all areas of anxiety.

Understand that beta blockers do not directly reduce anxiety. You will still feel nervous days before a performance and worried. But, when the performance begins, your hands will not be shaking and you will be in control. After experiencing this a few times, knowing that you will be successful in performance often reduces pre-performance anxiety. But again, beta blockers do not lessen feelings of panic or anxiousness in the same way tranquilizers or sedatives do.

SEE A DOCTOR FIRST

Any drug should only be taken with your doctor’s consent. NEVER take a drug offered by a well-meaning friend without consulting with a physician first.

Although these are relatively benign drugs for most people, you may have known or unknown health problems that could cause a bad reaction with these drugs.

The following people should not take beta-blockers:

• Patients with a history of asthma (unless the doctor says so)
• Patients with a history of bronchospasm (unless the doctor says so)
• Patients with second or third degree heart block
• Patients with severe peripheral arterial disease (including Raynaud's syndrome)
• Patients with worsening, unstable heart failure (can be used for stable heart failure)

For the following people, beta-blockers should be used with caution:

• Patients with diabetes, especially those with regular episodes of low blood sugar (hypoglycemia)
• Patients with MG (myasthenia gravis)
• Patients with a slow heart rate (bradycardia)
• Patients with low blood pressure (hypotension)
• Patients with hypertension that results from an adrenal gland tumor (pheochromocytoma)
• Patients with high blood acid levels (metabolic acidosis)
• Patients with Prinzmetal angina.

This is by no means a comprehensive list. SEE YOUR DOCTOR FIRST.

Do not purchase pills on the Internet unless your doctor says a particular website is okay.

Side Effects

In the United States, when a drug is advertised or is purchased, a list of side effects is always provided. The list usually goes on for several pages, usually in fine print. Inevitably, one of the side effects is death! Drug companies must do this to limit their liability. In most cases, the drugs are safe and the dire side effects very rare. I don’t mean to scare you off from considering beta blockers. But, here are commonly listed side effects from the use of beta blockers:

• Fatigue
• Cold hands
• Headache
• Upset stomach
• Constipation
• Diarrhea
• Dizziness
• Shortness of breath
• Trouble sleeping
• Loss of sex drive/erectile dysfunction
• Depression
• Nausea
• Vomiting
• Blurred vision
• Disorientation
• Hair loss
• Weakness
• Muscle cramps
• Cold hands and feet
• Slow heartbeat
• Edema (swelling in ankles, feet, or legs)

I find it very interesting that several of the listed side effects are things beta blockers usually prevent!

Real-World Usage

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 (a brand name) controlled stage fright. As long ago as 1987, a study of the 51 largest orchestras in the U.S. found that one in four musicians used them to improve their live performances. In more recent surveys, more than half of professional musicians and music teachers have reported using them. The figures are thought to be higher among conservatory students.

Again, in themselves, beta blockers do not directly enhance a performance. They do not directly help your concentration. They do not directly help your confidence.

But, because they eliminate many of the physical symptoms of stage fright such as hand and finger shakes, indirectly they DO help concentration (you are no longer worried about controlling shaky fingers so you can focus on the music) and they DO increase your confidence (again because you know you don’t have to deal with shaky fingers and hands).

Therefore, you can give amazingly good public performances.

Controversy

The use of beta blockers is not without a degree of controversy—they’re illegal for Olympians, although use for stage fright is medically approved—and many people who use beta blockers decline to go on the record about them.

There is disagreement among musicians concerning their use. To St. Louis Symphony Orchestra principal horn player Roger Kaza, taking beta blockers for performance anxiety is the equivalent of taking aspirin for a headache.

Kaza stresses that the use of beta blockers should not be equated with performance-enhancing drugs, many of them dangerous to the user, such as the steroids, hormones and blood doping used by some athletes to make them stronger or faster.

Those “have nothing to do with the drugs performers take,” he says. “Beta blockers are more in the vein of medical impairment/treatment. Think headache/aspirin, sniffles/antihistamine, performance anxiety/beta blockers. It’s funny that some people are ashamed of it. If you were against all medicine — if you were a Christian Scientist—that would be one thing, but if you take medications for other things, I don’t see the problem.”

To retired St. Louis Symphony violinist Darwyn Apple, they give the performer who takes them an unfair advantage over others. “The playing field is not level,” when some performers have what he calls a chemical advantage.

Dr. Kenneth Rybicki, an internist and clinical instructor at the Washington University School of Medicine in St. Louis, stresses the importance of using beta blockers under a doctor’s supervision. They can have side effects from sleepiness to diabetes, nightmares and bronchial constriction, and can be fatal for asthmatics.

Dr. Randi Mozenter, a clinical psychologist at Barnes-Jewish HealthCare, deals regularly with musicians and performance anxiety. She doesn’t think using blockers is an issue. “It’s an individual decision between the person and their physician,” she said.

Mozenter thinks that some performers are more prone to stage fright than others. “I would bet that it differs by instrument. I would guess that orchestra people are much more likely to have performance anxiety than the average rock musician. If you don’t feel comfortable when performing, it’s not fun for the audience, either,” she said. “If you’re able to enjoy playing with blockers then take them.”

Viewpoints: Do Beta Blockers Improve a Musician’s Performance?

NO
Violinist Darwyn Apple thinks the use of beta blockers changes more than stage fright. “I can pretty much tell who’s used them. There’s a whole different sense of energy that comes from them when they’re ready to perform that seems really artificial. There’s a distance. It’s a whole different zone that I don’t want to be in.”

Instead, says Apple, “I use the adrenaline. There’s no holding back. The music is a powerful force, and I don’t think it should be corrupted by the use of drugs.”

YES
The response to that line of thinking is beta blockers allow the performer to not hold back. The guitarist is no longer constrained by having to deal with stage fright. Now, the performer can give 100% emotionally and expressively. There is nothing artificial or corrupted about the performance at all. It is the guitarist finally being allowed to perform at his best.

NO
St. Louis Symphony concertmaster David Halen says, “Sometimes it seems very apparent” that a performer is using beta blockers. “My personal feeling is that it’s better when people don’t take them because sometimes some nervousness can actually make great music. If somebody’s a little bit too comfortable, sometimes it ends up affecting accuracy as much as a little bit of nervous energy, but in the opposite direction; it can be a little bit boring.”

YES
Please. There is a big difference between a little nervousness, a somewhat elevated pulse, or a little anxiety and the common pronounced stage fright where your heart is pounding out of your chest, your hands are literally trembling, and you are ready to throw up. Real stage fright will not “help” a performance. It will ruin it. The performance will not be boring unless it was already boring in the practice room. With beta blockers, the performer can play with all his feeling, energy, and enthusiasm. He will not be hobbled by symptoms of stage fright.

NO
Performance anxiety consists of three elements: physical effects, mental effects, and emotional effects. Beta blockers only effectively target the physical effects. They do not address focus and concentration issues, self-doubt, self-criticism, over-analysis, memory slips, and feelings of panic. Studies suggest that the mental and emotional components of performance anxiety are more to blame for poor performances than the physical elements.

YES
Once again, by controlling the physical manifestations of panic, beta blockers do indeed solve most other problems as well. However, it is of course true that if you have problems with focus and concentration, memory slips, etc. in the practice room, they certainly are not going to go away in a live performance by taking beta blockers. Duh.

NO
Peak performance requires a tremendous amount of energy. Peak performance–those rare moments when everything just “clicks” and your performance is truly inspired – requires intense concentration, focus, and energy. When you are playing by yourself in the practice room, the energy that fuels peak performance is not available to you. It is only when you get on stage and the adrenaline kicks in that you have access to this energy.

YES
The “energy” created by pure panic is not helpful to a performance. It is debilitating. It is for fighting off a saber-toothed tiger, not playing the Bach Chaconne. If a performer wants to experience a controlled surge of adrenaline, he can adjust the dosage of the beta blocker. When the fear of making tons of mistakes from shaking hands is removed, the performer can unleash his energy and produce the most exciting and energetic performances of his career.

Do It Right

If you want to try beta blockers:

1. DO NOT EVER TAKE THESE DRUGS WITHOUT SEEING YOUR DOCTOR FIRST.
   Some doctors are not familiar with the use of beta blockers to treat performance anxiety. If your doctor does not want to prescribe them for you, try a different doctor who is more familiar with this usage and who agrees they are a good solution.
2. Purchase them from a reputable pharmacy.
3. Test them first. Take one pill on a day when you are not giving a performance. Note any side effects, particularly headache or vision problems. If you experience any adverse side effects, go back to the doctor and discuss them with him. The doctor may decide to prescribe a different beta blocker. There are many. Or, simply taking a smaller dose may solve the problem.
4. Take the pill one hour before the start of the performance. Its effectiveness should easily last for 2-5 hours.
5. If the pill did not seem to control your hand and finger shaking as well as you had hoped, slightly increase the dosage at the next performance. If you want to feel some extra adrenaline buzz, reduce the dosage.

Other than that solution, finding something that works for you to reduce performance anxiety may take a long time. You may find things that work a little or sometimes, or that work for a while and then don’t. The intensity of your stage fright also may change with age.

Stage fright is malevolent. Performance anxiety can prevent you from doing what you enjoy and if you are a professional, can affect your career. Performance anxiety can also affect your self-esteem and self-confidence in general.

You are not alone. Stage fright is the bane of almost every performer’s existence. Severe anxiety has interfered with the work of classical musicians, including guitarist Andrés Segovia, cellist Pablo Casals and pianists Vladimir Horowitz, Glenn Gould and Van Cliburn. Pop performers — from Barbra Streisand and Andrea Bocelli to Carly Simon and Rod Stewart — have suffered intensely from it. Some very famous musicians and actors vomit before every performance.

Symptoms of Stage Fright

Performance anxiety symptoms may include:

• Racing pulse and rapid breathing
• Dry mouth and tight throat
• Trembling hands, knees, lips, and voice
• Sweaty and cold hands
• Nausea and an uneasy feeling in your stomach
• Vision changes
• Sudden overwhelming fear
• Palpitations
• Shortness of breath
• Sense of choking
• Chest pain
• Dizziness
• A feeling of being detached from the world
• Numbness or tingling in the limbs or entire body
• Chills or hot flushes

Of Course, You’re Scared to Death

I quote here from a previous Technique Tip of the Month titled, How to Give a Performance Without Making a Complete Fool of Yourself:

As science uncovers new information about the wonders of the human brain, we marvel at its abilities. But the brain also displays abilities that, while designed to ensure our survival, are sometimes out of sync with the requirements of our daily lives. One of those is its fear-response programming.

For instance, our brains identify the following four things as being very bad for survival:

• Standing alone
• In open territory with no place to hide
• Without a weapon
• In front of a large crowd of creatures staring at you

Does any of that sound vaguely familiar to you? How about:

• Sitting alone in a chair with a footstool
• On an open stage
• With just a guitar in your lap (for the most part, not an effective weapon)
• In front of a crowd of people staring at you

Any creature, especially a human, finding itself in the above situation knows the odds are high it will soon be attacked and eaten alive. Many predators hunt in packs. Their easiest prey are those who stand alone, in open territory with no cover, without a weapon or other effective means of defense. Our brains are wired to fear what it knows is the worst tactical situation for a person to be in. This fear resides in the amygdala, one of the oldest parts of our brain that regulates our breathing, heart rate, and many other things. There is no way to turn it off.

Even though our fear-response wiring is essential to our survival in dangerous situations, it can get in the way of modern daily life. It is automatically applied to non-survival but stressful situations in our daily life such as performing. Oftentimes it leads to high blood pressure, ulcers, headaches, and other physical symptoms.

It is Worse for Classical Guitarists

For us classical guitarists, stage fright is extremely difficult to deal with. Both our hands must make micro-movements that leave no room for error, often at high speed. If our hands shake the slightest amount, our performance turns into a disaster. Controlling stage fright for a pianist, for example, is far easier. Compared with the thin strings of a guitar, piano keys are wide objects, relatively easy to hit accurately, even when you are shaking. I don’t mean to insult pianists, but that’s the truth.

Also, the classical guitarist usually performs alone. Performing alone generates a far greater amount of performance anxiety than playing in a duo or a group. In a concert situation, not only is the guitarist alone, but because of the low volume produced by the instrument, the audience is exceedingly quiet and focused on every sound the guitarist produces. As the guitarist performs, he feels that intense focus, heightening his feeling of vulnerability.

Commonplace (and often ineffective) Performance Anxiety Treatments

On medical websites such as WebMd,countless musicians’ websites, and from specialists in performance anxiety treatment, you will find suggestions such as these to combat stage fright.

• Be prepared: practice, practice, practice.
• Limit caffeine and sugar intake the day of the performance. Eat a sensible meal a few hours before you are to perform so that you have energy and don't get hungry. A low-fat meal including complex carbohydrates—whole-grain pasta, lentil soup, yogurt, or a bean and rice burrito— is a good choice.
• Shift the focus off yourself and your fear to the enjoyment you are providing to the spectators. Close your eyes and imagine the audience laughing and cheering, and you feeling good.
• Don't focus on what could go wrong. Instead focus on the positive. Visualize your success.
• Avoid thoughts that produce self-doubt.
• Practice controlled breathing, meditation, biofeedback, and other strategies to help you relax and redirect your thoughts when they turn negative. It is best to practice some type of relaxation technique every day, regardless of whether you have a performance, so that the skill is there for you when you need it.
• Take a walk, jump up and down, shake out your muscles, or do whatever feels right to ease your anxious feelings before the performance.
• Connect with your audience -- smile, make eye contact, and think of them as friends.
• Act natural and be yourself.
• Exercise, eat a healthy diet, get adequate sleep, and live a healthy lifestyle.

Keep in mind that stage fright is usually worse before the performance and often goes away once you get started.

There are also mental tricks you can play to help you perform with less anxiety. These include:

• Focus on the friendliest faces in the audience.
• Laugh when you can, it can help you relax.
• Make yourself look good. When you look good, you feel good.

These tips should help reduce performance anxiety. But if they don't, talk to a counselor or therapist trained in treating anxiety issues. You may benefit from more intensive therapy, such as cognitive behavioral therapy, to help overcome performance anxiety.

Don’t misunderstand. These are all great suggestions. But I call them “Commonplace and often ineffective” treatments because these will generally work only on mild cases of stage fright for some people. And, they may not work well enough in the unique circumstances of the classical guitarist. Some treatments such as biofeedback and cognitive behavioral therapy have helped some people. Cognitive behavioral therapy, or CBT, gets people to tackle the psychological and emotional underpinnings of their stage fright to help them counter much of the negative internal talk that's associated with the condition. Specific techniques include recognizing irrational and unfounded beliefs, avoiding the revisitation of an "activating event" (i.e. a recent negative experience), and learning how not to obsess over the fear of negative consequences. And, just simply talking it out with a therapist has also been shown to be effective.

Some doctors claim results with CBT in only 8-10 therapy sessions. Others say benefits are seen in 12-16 weeks depending on the individual. Typically, a 45-minute session costs $150 and up. For some people, a large investment of time and money will be required for effective, professional treatment. But certainly, if it works, it is time and money well spent.

Other treatment options include hypnosis, meditation, and visualization. Visualization techniques can be effective. They create an identifiable, positive image in a person's mind about the desired outcome. Some people even use visualizations of everything that could possibly go wrong, which they come to accept as possibilities (sounds unintuitive and runs counter to other advice, but it works for them).

Goofy Things Can Work

Don’t denigrate anything that works. Weird or nonsensical cures work because you believe they work. If you believe that eating a special food on performance day helps, do it. Believing is 99% of the battle. For me, I believe that eating donuts or pancakes and caffeine before a concert is very helpful. Some people have a lucky ring, or wear lucky shoes. Or they follow a ritual routine on the day of the concert.

It doesn’t matter what it is. It doesn’t matter whether it is scientifically proven. If you have convinced yourself that it works, then do it.

Ask yourself, “Do I Want to Bother with This?”

It is important to consider a few things and ask yourself a few questions.

First, people with stage fright shouldn't feel that they must get over stage fright and force themselves into performance situations that make them feel exceedingly uncomfortable. Every person with performance anxiety needs to consider just how important it is to them to deal with the effects of stage fright. Sometimes it is simply not worth it.

Some people feel like they must perform. I don’t understand that. I am quite happy just playing for myself. I love the guitar and I like the music I learn and play. Although I make my living doing it, I have no compelling need to perform publicly or record it for anyone else to hear. I understand how odd it sounds, but it’s the truth.

Some say it isn’t worth it and give up trying to perform altogether or perform only in certain non-threatening situations (for friends, the dog, at church, retirement homes, hospitals). Or, they perform in duos or chamber groups with more people which, for some, will lessen anxiety.

A Couple of Obvious Helpful Hacks

Play pieces that are easy for you. If you are playing pieces that you can barely get through at home, or only play well 1 out of 10 times at home, you will be in trouble trying to play that piece for an audience. It will usually fail miserably.

Some people’s anxiety stems from lack of confidence in their memorization of a piece. The cure? Use the music!

Play music with which you are totally comfortable. If playing traditional hardcore classical repertoire is crushing you, try performing other types of music using classical guitar technique. Someone who has a difficult time playing Capricho Árabe in public may do perfectly fine playing a nice fingerstyle jazz arrangement of Summertime or a fingerstyle arrangement of a bossa nova tune.

The Power of Prayer

If you have a strong faith, prayer may very well be the easy and simple answer for you.

A Few Ridiculous Assertions

1. You just have to perform more. Put yourself in stressful situations and you will get used to them. You will adapt. Your anxiety will decrease over time.

This is ridiculous advice. This may work for a few, but for most it will be disastrous. Every failed performance will compound the anxiety.

2. A performer has a right—even a responsibility—to be nervous, which they must overcome by preparing so thoroughly that they will do well in spite of it.

More ridiculous advice. I’m sorry, but if the piece is difficult, or a person has significant performance anxiety, they won’t do a good job performing the piece no matter how thoroughly prepared they are.

3. Prepare, prepare, prepare. If you are prepared, you won’t get nervous.

This simplistic and ridiculous advice is similar to the preceding. Preparation is one essential element, but is not enough to alleviate pronounced stage fright.

Bad Ideas

1. Alcohol. Drinking seemingly worked for some performers but many also became alcoholics.
2. Marijuana and illegal drugs. One well-known musician who suffered stage fright when playing recitals couldn’t use beta blockers because of asthma (see below), but still found a solution to the problem. Instead of popping a pill, “I would smoke half a joint before a recital, and finish it during intermission. The recordings sounded great!” For some performers that may work, for others it could be disastrous. The use of hard drugs to control stage fright is definitely a bad idea. It has led many performers to addiction.
3. Tranquilizers. They will relieve anxiety but forget about doing much more than successfully walking out on stage, sitting down, and strumming a C chord.

OKAY, THIS IS IT:
The One and Only Surefire, Quick, and Inexpensive Way to Control Stage Fright:

BETA BLOCKERS

Remember our earlier discussion of the brain’s fear-response programming? In a Ted-Ed video, Mikael Cho describes it this way (with some additions by me):

Humans are wired to worry about their reputation. Performing in public can threaten that. Before a performance you may think, “What if people think I’m awful? What if I am awful? What if I forget the music? They will think I’m a failure.”

That fear is a threat reaction from a primitive part of your brain that is very hard to control. It’s the fight-or-flight response, a self-protective process seen in a wide range of animals, most of which don’t give concerts.

To your conscious modern mind, you are giving a concert. To the rest of your brain, programmed with the “law of the jungle”, when you perceive the possible consequences of blowing a performance, it is time to run for your life. Or, fight to the death.

Your hypothalamus, common to all vertebrates, triggers the pituitary gland to secrete the hormone ACTH, making your adrenal glands shoot adrenaline into your blood. Your neck and back tense up, you slouch, your legs and hands shake as your muscles prepare for attack. You sweat, your blood pressure jumps. Your digestion shuts down to maximize the delivery of nutrients and oxygen to muscles and vital organs. You get dry mouth and butterflies. Your pupils dilate, so it’s hard to read anything up close. Your fingers may go out-of-focus on the fretboard. Your may have difficulty reading your music. But long-range vision is good. That’s how stage fright works.

The goal is to not let your hypothalamus convince your body it’s about to be lunch for a pack of predators. You cannot overcome stage fright. But you can adapt to stage fright. Remember, no matter how civilized and cultured you may seem, in part of your brain, you are still a wild animal. A profound, well-spoken wild animal who plays the classical guitar.

This is why dealing with stage fright is so difficult. We are attempting to shut down or control a part of us that is trying its best to save and protect us at a primordial level.

Finally, A Solution to Control Stage Fright or Performance Anxiety

The one thing that does work for most people in controlling performance anxiety is beta blockers. Beta blockers are pills. They are a class of prescribed drugs.

Beta blockers such as propranolol (often referred to by the brand name, Inderal) are used to treat everything from hypertension to heart attacks to tension headaches. They slow the heart rate, fight off stress hormones and restrain the amygdala, the part of the brain that controls emotional reactions.

That, in turn, calms the fight-or-flight reaction that can make hearts race, hands and fingers shake, palms go sweaty, and minds go blank. It can make a nervous musician calm in a performance, or make a difficult solo go more smoothly. A 10 or 20 milligram dose (a typical prescription for high blood pressure is 40 milligrams) will keep its taker calm for two to four hours.

In medical jargon, beta-blockers block beta-adrenergic substances, such as apinephrine (adrenaline) in the autonomic nervous system (involuntary nervous system). They slow down the heartbeat, decrease the force of the contractions of the heart muscles, and reduce blood vessel contraction in the heart, brain, as well as the rest of the body. They are prescribed by doctors to treat a wide variety of conditions.

For the musician, beta blockers stop the shaking of hands and fingers. Completely. Knowing you will have excellent motor control under the most stressful performance circumstances helps reduce all areas of anxiety.

Understand that beta blockers do not directly reduce anxiety. You will still feel nervous days before a performance and worried. But, when the performance begins, your hands will not be shaking and you will be in control. After experiencing this a few times, knowing that you will be successful in performance often reduces pre-performance anxiety. But again, beta blockers do not lessen feelings of panic or anxiousness in the same way tranquilizers or sedatives do.

SEE A DOCTOR FIRST

Any drug should only be taken with your doctor’s consent. NEVER take a drug offered by a well-meaning friend without consulting with a physician first.

Although these are relatively benign drugs for most people, you may have known or unknown health problems that could cause a bad reaction with these drugs.

The following people should not take beta-blockers:

• Patients with a history of asthma (unless the doctor says so)
• Patients with a history of bronchospasm (unless the doctor says so)
• Patients with second or third degree heart block
• Patients with severe peripheral arterial disease (including Raynaud's syndrome)
• Patients with worsening, unstable heart failure (can be used for stable heart failure)

For the following people, beta-blockers should be used with caution:

• Patients with diabetes, especially those with regular episodes of low blood sugar (hypoglycemia)
• Patients with MG (myasthenia gravis)
• Patients with a slow heart rate (bradycardia)
• Patients with low blood pressure (hypotension)
• Patients with hypertension that results from an adrenal gland tumor (pheochromocytoma)
• Patients with high blood acid levels (metabolic acidosis)
• Patients with Prinzmetal angina.

This is by no means a comprehensive list. SEE YOUR DOCTOR FIRST.

Do not purchase pills on the Internet unless your doctor says a particular website is okay.

Side Effects

In the United States, when a drug is advertised or is purchased, a list of side effects is always provided. The list usually goes on for several pages, usually in fine print. Inevitably, one of the side effects is death! Drug companies must do this to limit their liability. In most cases, the drugs are safe and the dire side effects very rare. I don’t mean to scare you off from considering beta blockers. But, here are commonly listed side effects from the use of beta blockers:

• Fatigue
• Cold hands
• Headache
• Upset stomach
• Constipation
• Diarrhea
• Dizziness
• Shortness of breath
• Trouble sleeping
• Loss of sex drive/erectile dysfunction
• Depression
• Nausea
• Vomiting
• Blurred vision
• Disorientation
• Hair loss
• Weakness
• Muscle cramps
• Cold hands and feet
• Slow heartbeat
• Edema (swelling in ankles, feet, or legs)

I find it very interesting that several of the listed side effects are things beta blockers usually prevent!

Real-World Usage

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 (a brand name) controlled stage fright. As long ago as 1987, a study of the 51 largest orchestras in the U.S. found that one in four musicians used them to improve their live performances. In more recent surveys, more than half of professional musicians and music teachers have reported using them. The figures are thought to be higher among conservatory students.

Again, in themselves, beta blockers do not directly enhance a performance. They do not directly help your concentration. They do not directly help your confidence.

But, because they eliminate many of the physical symptoms of stage fright such as hand and finger shakes, indirectly they DO help concentration (you are no longer worried about controlling shaky fingers so you can focus on the music) and they DO increase your confidence (again because you know you don’t have to deal with shaky fingers and hands).

Therefore, you can give amazingly good public performances.

Controversy

The use of beta blockers is not without a degree of controversy—they’re illegal for Olympians, although use for stage fright is medically approved—and many people who use beta blockers decline to go on the record about them.

There is disagreement among musicians concerning their use. To St. Louis Symphony Orchestra principal horn player Roger Kaza, taking beta blockers for performance anxiety is the equivalent of taking aspirin for a headache.

Kaza stresses that the use of beta blockers should not be equated with performance-enhancing drugs, many of them dangerous to the user, such as the steroids, hormones and blood doping used by some athletes to make them stronger or faster.

Those “have nothing to do with the drugs performers take,” he says. “Beta blockers are more in the vein of medical impairment/treatment. Think headache/aspirin, sniffles/antihistamine, performance anxiety/beta blockers. It’s funny that some people are ashamed of it. If you were against all medicine — if you were a Christian Scientist—that would be one thing, but if you take medications for other things, I don’t see the problem.”

To retired St. Louis Symphony violinist Darwyn Apple, they give the performer who takes them an unfair advantage over others. “The playing field is not level,” when some performers have what he calls a chemical advantage.

Dr. Kenneth Rybicki, an internist and clinical instructor at the Washington University School of Medicine in St. Louis, stresses the importance of using beta blockers under a doctor’s supervision. They can have side effects from sleepiness to diabetes, nightmares and bronchial constriction, and can be fatal for asthmatics.

Dr. Randi Mozenter, a clinical psychologist at Barnes-Jewish HealthCare, deals regularly with musicians and performance anxiety. She doesn’t think using blockers is an issue. “It’s an individual decision between the person and their physician,” she said.

Mozenter thinks that some performers are more prone to stage fright than others. “I would bet that it differs by instrument. I would guess that orchestra people are much more likely to have performance anxiety than the average rock musician. If you don’t feel comfortable when performing, it’s not fun for the audience, either,” she said. “If you’re able to enjoy playing with blockers then take them.”

Viewpoints: Do Beta Blockers Improve a Musician’s Performance?

NO
Violinist Darwyn Apple thinks the use of beta blockers changes more than stage fright. “I can pretty much tell who’s used them. There’s a whole different sense of energy that comes from them when they’re ready to perform that seems really artificial. There’s a distance. It’s a whole different zone that I don’t want to be in.”

Instead, says Apple, “I use the adrenaline. There’s no holding back. The music is a powerful force, and I don’t think it should be corrupted by the use of drugs.”

YES
The response to that line of thinking is beta blockers allow the performer to not hold back. The guitarist is no longer constrained by having to deal with stage fright. Now, the performer can give 100% emotionally and expressively. There is nothing artificial or corrupted about the performance at all. It is the guitarist finally being allowed to perform at his best.

NO
St. Louis Symphony concertmaster David Halen says, “Sometimes it seems very apparent” that a performer is using beta blockers. “My personal feeling is that it’s better when people don’t take them because sometimes some nervousness can actually make great music. If somebody’s a little bit too comfortable, sometimes it ends up affecting accuracy as much as a little bit of nervous energy, but in the opposite direction; it can be a little bit boring.”

YES
Please. There is a big difference between a little nervousness, a somewhat elevated pulse, or a little anxiety and the common pronounced stage fright where your heart is pounding out of your chest, your hands are literally trembling, and you are ready to throw up. Real stage fright will not “help” a performance. It will ruin it. The performance will not be boring unless it was already boring in the practice room. With beta blockers, the performer can play with all his feeling, energy, and enthusiasm. He will not be hobbled by symptoms of stage fright.

NO
Performance anxiety consists of three elements: physical effects, mental effects, and emotional effects. Beta blockers only effectively target the physical effects. They do not address focus and concentration issues, self-doubt, self-criticism, over-analysis, memory slips, and feelings of panic. Studies suggest that the mental and emotional components of performance anxiety are more to blame for poor performances than the physical elements.

YES
Once again, by controlling the physical manifestations of panic, beta blockers do indeed solve most other problems as well. However, it is of course true that if you have problems with focus and concentration, memory slips, etc. in the practice room, they certainly are not going to go away in a live performance by taking beta blockers. Duh.

NO
Peak performance requires a tremendous amount of energy. Peak performance–those rare moments when everything just “clicks” and your performance is truly inspired – requires intense concentration, focus, and energy. When you are playing by yourself in the practice room, the energy that fuels peak performance is not available to you. It is only when you get on stage and the adrenaline kicks in that you have access to this energy.

YES
The “energy” created by pure panic is not helpful to a performance. It is debilitating. It is for fighting off a saber-toothed tiger, not playing the Bach Chaconne. If a performer wants to experience a controlled surge of adrenaline, he can adjust the dosage of the beta blocker. When the fear of making tons of mistakes from shaking hands is removed, the performer can unleash his energy and produce the most exciting and energetic performances of his career.

Do It Right

If you want to try beta blockers:

1. DO NOT EVER TAKE THESE DRUGS WITHOUT SEEING YOUR DOCTOR FIRST.
   Some doctors are not familiar with the use of beta blockers to treat performance anxiety. If your doctor does not want to prescribe them for you, try a different doctor who is more familiar with this usage and who agrees they are a good solution.
2. Purchase them from a reputable pharmacy.
3. Test them first. Take one pill on a day when you are not giving a performance. Note any side effects, particularly headache or vision problems. If you experience any adverse side effects, go back to the doctor and discuss them with him. The doctor may decide to prescribe a different beta blocker. There are many. Or, simply taking a smaller dose may solve the problem.
4. Take the pill one hour before the start of the performance. Its effectiveness should easily last for 2-5 hours.
5. If the pill did not seem to control your hand and finger shaking as well as you had hoped, slightly increase the dosage at the next performance. If you want to feel some extra adrenaline buzz, reduce the dosage.

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A Final Helpful Hint

If you want to do more research on stage fright, here is a helpful hint. Google “stage fright” or “musicians performance anxiety”. Do not Google “performance anxiety”. That will lead you to articles about using Viagra, Cialis, etc. to cure a very different type of anxiety. Those drugs will NOT be helpful while you are onstage trying to perform Leyenda!