How to treat stage fright

Last updated: July 2011

The actor Laurence Olivier described it as shattering. The pianist Vladimir Horowitz found it so disabling that he didn't perform for 12 years. Stage fright—also known as performance anxiety—strikes all kinds of people, including surgeons, athletes, students, pilots, and even public speakers. Indeed, 40 percent of adults in the U.S. dread speaking in front of an audience, a 2001Gallup poll found.

While many people feel apprehensive in such situations, those with performance anxiety suffer from an intense fear of humiliation, embarrassment, or scrutiny by others. A stressful event such as a music recital or speech sets off their body's "fight or flight" response, triggering symptoms such as heavy sweating, heart palpitations, trembling, blushing, dry mouth, gastrointestinal distress, and hyperventilation. The anxiety drives some to abandon successful careers or self-medicate with alcohol or drugs.

But other people sometimes use beta-blockers, most commonly propranolol (Inderal and generic), as well as pindolol (Visken and generic); acebutolol (Sectral and generic); and atenolol (Tenormin and generic). The Food and Drug Administration approved beta-blockers for the treatment of high blood pressure, heart conditions, and certain types of tremors, and for the prevention of migraines and repeat heart attacks. Yet for more than 30 years, they have also been used off-label—meaning for a condition other than those approved by the FDA—to blunt the symptoms of performance anxiety. (Doctors can legally prescribe any medication they deem appropriate to treat a patient's condition.) Beta-blockers might prevent some of the effects of adrenaline, the body's "fight-or-flight" hormone.

"Taken an hour before a performance, beta-blockers will reliably decrease symptoms like a pounding heart and a trembling voice or hands," says Franklin Schneier, M.D., a research psychiatrist in the Anxiety Disorders Clinic at the New York State Psychiatric Institute and a professor of psychiatry at the Columbia University College of Physicians and Surgeons. "But a moderate level of anxiety energizes a performance, so beta-blockers may actually reduce performance quality in people who are not very anxious. Also, people often become psychologically dependent on them and feel they need one before every performance, rather than learning skills to manage their anxiety."

What is the evidence?

Studies on the value of beta-blockers for performance anxiety are limited by small sample sizes, the lack of blinding or placebo control, subjective anxiety ratings, and other shortcomings. Most note greater improvement in physical as opposed to psychological symptoms. Below is a summary of the evidence grouped by performance category.

Music. Student musicians received the beta-blocker propranolol or a placebo 90 minutes before a recital. The drug reduced one of the physical effects of stage fright—dry mouth—and also enhanced performance. Another beta-blocker, nadolol (Corgard and generic), when compared with a tranquilizer, decreased pulse rates and tremors in student string players, improving their bow control. In a study of student singers, low-dose nadolol was marginally beneficial but not in higher doses.

Public speaking. Anxious subjects received propranolol or a placebo before giving a videotaped speech. The beta-blocker significantly reduced anxiety symptoms as rated by the subjects and by trained observers. Compared with a placebo, propranolol also improved word recall in subjects with higher anxiety but hindered it in those with lower anxiety.

Surgery. Ophthalmology residents were given propranolol or a placebo one hour before performing complex and delicate eye surgery. The study reported that propranolol decreased surgical tremors and anxiety but couldn't say whether or not it helped with how well the surgery went.

Test taking. In a placebo-controlled study, propranolol given to medical students with test anxiety before an exam slightly improved their performance in verbal reasoning and mental arithmetic. In another study, high school seniors who had already taken the Scholastic Aptitude Test (SAT) and reported stress-related cognitive dysfunction were given propranolol before retaking the exam. Their scores were higher compared with the average increase for students repeating the exam without medication. But other studies did not demonstrate such improvements, possibly because the baseline anxiety levels of the students weren't measured.

Sports. Beta-blockers can diminish performance in aerobic sports such as running, but they also reduce tremors and improve hand/arm steadiness in precision events. For that reason they are banned by the World Anti-Doping Agency for professional competition in archery, billiards, golf, shooting, and other sports.

What are the risks and warnings?

The following information applies to the use of propranolol for chronic medical conditions. Because beta-blockers are used intermittently and at a lower dose for performance anxiety, side effects are likely to be milder or less likely to occur.

Concerning medical conditions. Propranolol is not recommended if you have asthma, a slow heartbeat (bradycardia), Raynaud's syndrome, overt congestive heart failure, or certain heart-rhythm disorders. In addition, tell your doctor if you have had lung diseases, heart, liver, or kidney disease, diabetes, severe allergies, or thyroid problems.

Drug interactions.
Tell your doctor about any prescription and nonprescription medication you take, especially cimetidine (Tagamet); medication for migraine headaches, asthma, allergies, colds or pain; medication for heart disease or high blood pressure; reserpine; and vitamins.

Side effects. Report the following reactions to your doctor immediately: a slow, irregular heartbeat, difficulty breathing, a sore throat, unusual weight gain, swelling of the feet or hands, unusual bleeding, or chest pain. Side effects reported in studies of beta-blockers for performance anxiety include gastrointestinal distress, headaches, insomnia, nightmares, hallucinations, dizziness, lethargy, depression, low blood pressure, and a slowed heart rate.

Surgery. If you're having surgery, tell your doctor or dentist that you use propranolol, which might increase the risks associated with anesthesia.

Pregnancy. A slow heart rate, respiratory depression, and low blood sugar have been reported in newborns whose mothers took beta-blockers during pregnancy. Tell your doctor if you're pregnant, plan to become pregnant, or are breast-feeding.

What steps should you take first?

Try nondrug approaches. "Cognitive behavioral techniques can help most people and may obviate the need for medicine," Schneier says. That therapy teaches anxiety management and includes performance practice. You can sharpen your public speaking in workshops given by Toastmasters International. "Some people have anxiety because they haven't mastered the skills," he points out.

Be evaluated by a doctor before using beta-blockers. "You should be screened for asthma and have an electrocardiogram to check for heart abnormalities," Schneier says. Your doctor should also look for contributing causes of anxiety, such as alcohol withdrawal, thyroid problems, low blood sugar, mental disorders, and the use of stimulating medication or substances, including caffeine and nicotine.

Sample a trial dose before the day of your performance.
"Beta-blockers can cause lightheadedness if you have low blood pressure," Schneier warns. "It's a good idea to see how they affect you when you're not up on stage."

Bottom line. Many people find beta-blockers to be helpful in managing the physical symptoms of performance anxiety, even though this use is not supported by substantial evidence from well-designed studies. Behavioral or cognitive therapy in addition to medication for performance anxiety could also be beneficial. Our advice: Talk with your doctor about possible causes and all available treatments for performance anxiety. If nondrug approaches don't work, consider beta-blockers only after their risks and benefits have been thoroughly explained to you.

This off-label drug use report is made possible through a collaboration between Consumer Reports Best Buy Drugs and the American Society of Health-System Pharmacists. This is the 25th in a series based on professional reports prepared by ASHP.

These materials were made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by a multistate settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).

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