Behind the screen, the tremor is the whole verdict

TL;DR: Music performance anxiety is adrenaline doing its job at the worst possible time. It shakes the bow arm, destabilizes the breath, chills the fingers, and speeds the heart. Practicing the notes more does not fix it, because you already know the notes. What helps is practicing the conditions: play the excerpt cold, first thing, in front of people, recorded, with one shot at it. Protect your sleep. Cut the coffee on the day. Beta-blockers are widely used in orchestras and blocked tremor in one small trial from 1982, which is close to the whole evidence base. They are unsafe with asthma, a slow heart rate, or certain heart conditions, so they need a doctor. And if the dread is with you every day instead of only at auditions, that is a different problem and it is treatable. Tell Dr. Ash what happens to you.

There is an occupational cruelty specific to the screened audition. Every other kind of performance gives the listener more than the sound: presence, intent, the visible fact that you meant that phrase. Behind a screen there is only what came out of the instrument, and an unsteady bar is the entire verdict.

That is worth naming, because musicians often describe their nerves as a character flaw. It is an evaluated moment engineered to strip away everything except the part adrenaline damages most.

What does adrenaline do to a musician specifically?

It attacks the very mechanics the instrument depends on.

Bow arm and fingers. Adrenaline binds to beta-2 receptors in skeletal muscle and produces a fine physiological tremor. On a string instrument that tremor is audible in the bow. On piano it shows up in evenness. On winds it moves through the embouchure.

Breath. Under adrenaline, breathing goes shallow and high in the chest. Singers and wind players lose the low, supported airflow that phrasing depends on, and long phrases start failing near the end.

Peripheral circulation. Blood moves toward the large muscles and away from the extremities, so fingers go cold and lose sensitivity. String players describe losing the top layer of contact with the fingerboard.

Heart rate and attention. A racing heart pulls attention inward, and attention spent monitoring your own body is attention not spent listening. That is the mechanism behind the sensation of playing while standing outside yourself.

What works other than medication?

Performance simulation, which means practicing the conditions and not the notes.

By audition day the notes are learned. What is unpracticed is playing them once, cold, first thing in the morning, with no warm-up run, while people you cannot see decide something about your life. So build that. Play the excerpt as the first thing you do that day, with no second attempt allowed. Record yourself, because a running microphone reproduces a surprising amount of the physiological response. Play for people, then for people you find slightly intimidating. Run mock auditions with a screen in place.

Then the ordinary levers, which musicians skip more than anyone:

• Sleep the two nights before. Sleep debt raises resting adrenaline, so a late-night practice session can cost more than it adds.
• Reduce caffeine on the day. Caffeine raises adrenaline and heart rate directly. Do not stop cold if you drink it daily, since withdrawal brings its own headache and fog.
• Warm up the hands physically. Warm water, gloves, or a pocket warmer counteract the peripheral vasoconstriction that costs you sensitivity.
• Breathe out longer than you breathe in. Four counts in, six to eight out, for 90 seconds before you walk on.

Guidance from the Clinic

"Musicians apologize to me for this, which tells you how it gets talked about in a practice room. Your hands are doing what hands do under adrenaline. That is physiology, and the useful conversation is about which part of it we are treating and whether the rest of your year looks the way this week does."

Do musicians use beta-blockers, and do they work?

They do, widely, and the evidence is thinner than the practice.

Surveys of orchestral musicians have reported that a majority have used a beta-blocker at some point, most often propranolol before an audition or a solo. Those are surveys. They record what musicians do and believe, which is a different thing from a controlled result.

The direct trial evidence is close to a single study. Brantigan and colleagues in 1982 gave beta-blockade to musicians in a double-blind crossover and found tremor fell and blinded judges rated the performances better. It is small, it is more than 40 years old, and it is most of what exists for this use. A 2016 systematic review of propranolol across anxiety disorders rated the evidence low quality, though that review concerns diagnosed disorders and does not settle the situational question.

So the position to hold is this. The mechanism is sound, the safety profile is known from decades of cardiac use, the direct evidence for this use is limited, and a great many musicians find it helps. All four are true together, and the pages that give you three of them are selling something.

What it does not do is play the audition. It removes an obstacle between your preparation and the room, and if the preparation is not there, there is nothing for it to reveal. The full picture on dose and timing is on propranolol for performance anxiety.

Who should not take one?

Asthma or any reactive airway disease is the firmest stop, because propranolol is non-selective and can trigger bronchospasm. That matters twice over for singers and wind players, whose airway is the instrument.

Beyond that: a resting heart rate below about 55, heart block or a pacemaker, heart failure, low blood pressure, any beta-blocker already in use including glaucoma eye drops, a previous bad reaction, and pregnancy or breastfeeding. Insulin-treated diabetes needs a physician's review, since beta-blockade masks the warning signs of a low. The complete list is on who should not take propranolol.

Two more that apply to musicians who also train. Beta-blockers cap heart rate for hours, so any workout that day will read wrong on a watch. And the World Anti-Doping Agency prohibits beta-blockers in specific tested sports, which matters if you compete in one alongside your playing.

When is it more than audition nerves?

When it does not leave when the audition does.

If you have withdrawn from opportunities, if you feel dread on most days and not around specific events, if panic arrives untethered, if you have stopped attending studio class or lessons, or if alcohol has become part of how you get through performances, then the audition is one visible edge of something broader. Those conditions are treatable and they are treated differently, and cognitive behavioural therapy has a far stronger evidence base for social anxiety disorder than any beta-blocker.

Sorting that out is most of the value of an evaluation. Performance anxiety covers the distinction, and the Philadelphia page covers what is available locally for conservatory and university students.

Related at Fishtown Medicine

• Performance anxiety: what your body is doing
• Propranolol for performance anxiety
• Who should not take propranolol
• Performance anxiety in Philadelphia
• Presentation anxiety
• Are beta-blockers banned in sports?

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. US Food and Drug Administration. Inderal (propranolol hydrochloride) prescribing information. FDA Access Data.
6. World Anti-Doping Agency. The Prohibited List: P1 Beta-blockers.