ST. LOUIS — Stage fright is the bane of the performer's existence. Severe anxiety has interfered with the work of classical musicians, including guitarist Andres Segovia, cellist Pablo Casals and pianists Glenn Gould and Van Cliburn. Pop performers — from Barbra Streisand and Andrea Bocelli to Carly Simon and Rod Stewart — have suffered intensely from it.
The traditional treatment is a quick swig of alcohol, taken as needed, but that has obvious risks. Today, the possibilities include Valium, hypnotherapy, cognitive behavioral therapy, meditation, and, especially, the class of drugs known as beta blockers, widely known as "the musician's underground drug," or "better living through chemistry."
Beta blockers such as propranolol (often referred to by a 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 emotion.
That, in turn, calms the fight-or-flight reaction that can make heartbeats race, palms go sweaty, and minds go blank. It can make a nervous musician calm in an audition, or make a difficult solo go more smoothly. A 10 milligram dose (a typical prescription for high blood pressure is 40 milligrams) will keep its taker calm for four to five hours.
A 1987 study by the International Conference of Orchestra Musicians indicated that 27 percent of its polled members said they used beta blockers. 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.
Their use 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 blockers decline to go on the record about them. A spokeswoman for the Juilliard School responded to a request for comments with a curt, "We're going to pass on that story."
There is disagreement among musicians concerning their use. To St. Louis Symphony Orchestra principal horn Roger Kaza, taking beta blockers for performance anxiety is the equivalent of taking aspirin for a headache. To retired symphony violinist Darwyn Apple, they give the performer who takes them an unfair advantage over others. To some observers, they can make a performance dull.
A recent Facebook discussion about their use between present and former symphony members grew heated; only two participants responded to requests for interviews on the subject. Although anecdotal evidence suggests that their use is commonplace, some who had been previously open about them clammed up when asked directly.
Kaza plays an instrument known for humbling performers; he takes beta blockers as needed, for auditions, recitals and some orchestral performances "if it's certain repertoire that I know will be a little more anxiety-producing," he said.
Kaza, like others, stressed 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 said. "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."
Fight-or-flight is, he noted, "hardwired" into mammals through eons of evolution. "It clearly has a survival advantage and thus is passed on in the gene pool," Kaza said. Musicians at all levels have a lot on the line when they perform, from earning a living to the satisfaction of doing their best. Fear and anxiety can get in the way of that.
"We're nervous because we're comparing ourselves with a CD that's perfect," he said. "It's an impossible situation."
Apple strongly disagrees. "The playing field is not level," he said, of when some performers have what he calls a chemical advantage. "I practiced. I prepared. You have to be balanced and grounded to withstand the unfair competition."
He 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, said 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. Nobody seems to care in the performance industry; the only thing that seems to matter is cranking out the right notes in the right place. But a slip of the fingers does not destroy the artistry and full impact of a piece if you're a performer who's been properly trained."
Kenneth Rybicki, an internist and clinical instructor at Washington University School of Medicine, has prescribed beta blockers for musicians, usually at their specific request.
"My experience is that, for most of them, it's just for once in a while, if they really need something to calm things down," Rybicki said. "But if somebody said to me, 'Every time we rehearse I get nervous,' I would see if there are any other underlying causes."
Like most of those interviewed for this story, Rybicki stressed 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.
"When people are in situations which are anxiety-provoking, they get the same physiological reaction that they would if they were facing a bear in the woods," Mozenter said. "It is a very striking response, with sweating, rapid heartbeat, coldness in the extremities. The brain shifts to reacting instead of problem-solving; there can be feelings of impending doom. People end up in emergency rooms every day for (anxiety), thinking they're having a life-ending event."