Stage fright in a conservatory town

TL;DR: Philadelphia is packed with people who have to perform. Music students at Curtis, Temple, and the Academy of Vocal Arts. Orchestral players auditioning behind a screen. Medical and law students at Penn, Jefferson, Drexel, and Temple facing orals and boards. Everyone taking the Pennsylvania bar exam in July. When your heart pounds and your hands shake in those moments, that is adrenaline, and there is a pill that blocks it. Propranolol stops the shaking and leaves the fear. It is not safe for people with asthma, a slow heart rate, or certain heart conditions, and it is banned in some tested sports. Before anyone prescribes it, the question worth answering is whether your problem is the moment or your whole week, because those need different treatment. Tell Dr. Ash what happens to you.

There are cities where stage fright is a niche complaint. This is not one of them.

Within a few miles of my practice there is a conservatory that admits a few dozen students a year from thousands of applicants, an orchestra whose auditions are decided behind a screen where a single unsteady bar ends it, four medical schools, three law schools, and a bar exam that arrives every July and every February for people who have organized three years of their life around it. Add the actors, the singers, the litigators, the surgeons, and the founders pitching in University City, and you have a population where an adrenaline response at the wrong moment carries consequences that stick.

Why does Philadelphia produce so much of this?

Because the city concentrates evaluated performance in a small geography, and evaluated performance is what triggers the response.

The music schools are the most obvious. The Curtis Institute, the Academy of Vocal Arts, Temple's Boyer College, and the University of the Arts alumni network put a large number of young musicians into juries, recitals, and competition rounds every semester. Orchestral auditions add a specific cruelty: the screen removes everything except the sound, so a tremor in the bow arm is the whole verdict.

The professional schools are the second cluster. Penn, Jefferson, Drexel, and Temple graduate physicians who face oral boards, and Penn, Temple, and Drexel graduate lawyers who face the Pennsylvania bar. Both paths include moments where months of preparation are assessed in a couple of hours, and test anxiety works differently from stage fright in a way that changes what helps.

Then there is everybody else: the teacher observed by a principal, the engineer presenting to a board, the person giving a toast at a wedding in Old City who has been dreading it since March. The mechanism does not care about the setting, and it responds to being watched and judged.

What is happening in your body?

Your nervous system reads the room as a threat and prepares you to fight or run, and the chemical it uses is adrenaline.

Adrenaline binds to beta receptors in your heart, your lungs, your blood vessels, and your skeletal muscle. The heart beats faster and harder. A fine tremor develops in the muscles, which is a problem for a bow, a bassoon reed, a scalpel, or a page you are holding. Sweat glands open, the mouth dries, breathing goes shallow and high in the chest, and blood moves away from the gut toward the large muscles.

Then the loop closes on itself, because you notice the tremor, the noticing frightens you, and the fear releases more adrenaline. That is the spiral people describe afterwards, and it is why the moment gets worse the more you attend to it.

Does the beta-blocker everyone talks about work?

It blocks the physical half and leaves the other half alone.

Propranolol occupies those beta receptors so adrenaline cannot reach them. The heart rate stays near baseline, the hands stay still, the voice keeps its tone. It never touches the fear itself, because that comes from brain circuitry the drug does not treat. Patients describe the result the same way every time: still nervous in the head, quiet in the body.

Among classical musicians the practice is old and widespread. Surveys of orchestral players have reported that a majority have used beta-blockers at some point, which tells you the practice is common and does not tell you it is well studied. The direct trial evidence is thin: a small 1982 crossover study in musicians found reduced tremor and better blinded ratings, and a 2016 systematic review of propranolol across anxiety disorders rated the evidence low quality. The full picture is on the page for propranolol and performance anxiety.

What it will not do is prepare you. It removes an obstacle between your preparation and the room. If the preparation is not there, the drug has nothing to reveal.

Guidance from the Clinic

"A student came to me a week before a jury asking for something for her hands. What she told me in the next ten minutes was that she had stopped going to studio class, she was not sleeping, and she had been feeling this way since October. A tablet for Thursday would have been the wrong medicine for what she was describing, and she would have taken it and thought she had been helped."

Who should not take a beta-blocker for this?

The list is short and it is firm, because this is an elective use and there is nothing on the other side of the scale.

Nobody with asthma, COPD, or any reactive airway condition should take propranolol for nerves. It is non-selective, so it blocks the receptors that keep airways open, and it can trigger bronchospasm. That includes people who carry a rescue inhaler only for exercise. Beyond that: a resting heart rate under about 55, heart block or a pacemaker, heart failure, low blood pressure, an existing beta-blocker including glaucoma eye drops, a previous bad reaction to one, and pregnancy or breastfeeding.

A second group needs a physician's review before anything is prescribed. Diabetes treated with insulin matters most, because beta-blockade removes the tremor and pounding heart that warn you your glucose is falling. Raynaud's gets worse. Thyroid disease, liver disease, myasthenia gravis, a triptan for migraine, and any cardiac history all change the answer. The complete list is on the page for who should not take propranolol.

Two more that catch Philadelphia patients specifically. If you compete in a drug-tested sport, the World Anti-Doping Agency prohibits beta-blockers in a defined list that includes archery and shooting, which are the sports where they help most. And if you train by heart rate, whether that is a Schuylkill River loop or a structured plan, a dose caps your rate for hours and your zones will read low that day.

When is a beta-blocker the wrong answer?

When the problem is your whole week instead of your Thursday.

If dread arrives on most days and is not attached to a specific event, if panic comes with no trigger, if you have started avoiding studio class or declining opportunities, or if you are drinking to get through these moments, then blocking the tremor treats the visible part and leaves the rest in place. Those are treatable, and they are treated differently. Cognitive behavioural therapy has a much stronger evidence base for social anxiety disorder than any beta-blocker.

This is the distinction I care most about getting right, because a person who is deteriorating out of sight can present as somebody with a manageable request. Sorting the two takes a conversation, and it is most of the value of the visit.

Where can you get assessed for this in Philadelphia?

Start with a physician who will take the history properly, whether that is your primary care doctor, a student health service, or a practice like this one.

If you are a student, use what your school already provides. Curtis, Temple, Penn, Drexel, and Jefferson all have student health and counselling services, and the counselling side is where the more durable treatment lives. Musicians should also know that performing arts medicine is a recognized field with clinicians who understand juries and auditions as the occupational demands they are.

Fishtown Medicine sees patients across Greater Philadelphia through home visits and secure messaging, phone, and video, and by telemedicine in the 40 states where Dr. Ash is licensed. For this problem specifically, the visit is an evaluation: what happens to your body and when, a screen for the conditions that make beta-blockade unsafe, and a decision about whether the pattern is situational or something broader. If the answer is that a beta-blocker is not your treatment, you are told that and told what is.

When should you get help sooner?

Some symptoms need attention before the next audition, not after it.

• Chest pain or pressure, at rest or with exertion
• Fainting or nearly fainting
• A racing or irregular heartbeat that arrives with no trigger
• Panic that comes out of nowhere
• Avoidance that is costing you school, work, or relationships
• Any thought of harming yourself

That last one belongs on a page about auditions, because people arrive at pages about auditions while something much heavier is going on. If that is you, say so. In the United States you can call or text 988 for the Suicide and Crisis Lifeline at any hour, and Philadelphia's own crisis line is 215-685-6440.

Related at Fishtown Medicine

• Propranolol for performance anxiety
• Performance anxiety: what your body is doing
• Who should not take propranolol
• Direct primary care in Philadelphia
• Online mental health treatment

Scientific References

1. Brantigan CO, Brantigan TA, Joseph N. Effect of beta blockade and beta stimulation on stage fright. The American Journal of Medicine. 1982;72(1):88-94.
2. Steenen SA, van Wijk AJ, van der Heijden GJMG, van Westrhenen R, de Lange J, de Jongh A. Propranolol for the treatment of anxiety disorders: A systematic review and meta-analysis. Journal of Psychopharmacology. 2016;30(2):128-139.
3. Kenny DT. The Psychology of Music Performance Anxiety. Oxford University Press; 2011.
4. Fishbein M, Middlestadt SE, Ottati V, Straus S, Ellis A. Medical problems among ICSOM musicians: overview of a national survey. Medical Problems of Performing Artists. 1988;3(1):1-8.
5. Mayo-Wilson E, Dias S, Mavranezouli I, et al. Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry. 2014;1(5):368-376.
6. World Anti-Doping Agency. The Prohibited List: P1 Beta-blockers.