day 12: should i try beta blockers for audition nerves?

today's day 12 of the 12 days of auditions! (it's finally over!) it's the video series where each day i cover a different topic on how to take auditions. yesterday was day 11: how to get rid of audition nerves. this is all leading up to the new mini-course, how to advance at an orchestra audition 101. scroll down and click the button below to enroll!

guys.

this is a topic i've been wanting to address forever. it's something that people constantly ask me about, and i'm always too shy to say anything. 

"beta blockers. should i try them? what are the pros and cons?"

well. i've never said anything before. and that's because i can't recommend a medication for you! a DOCTOR'S gotta do that. so i found a doctor. and not just any doctor. it's the president of the american academy of family physicians. i called her and asked her every question i could think of about beta blockers. and she's amazing. i learned SO much, and you will too.

so. if you're having performance anxiety and you're thinking about beta blockers... START HERE. learn about them. here's what you're going to learn:

1. the pros and cons of beta blockers

2. how to take them the right way (spoiler alert: get a doctor's appointment!)

3. the alternatives that you should try first

4. who should definitely NOT take them

5. ...and more!

so here it is. the epic interview about the pros and cons of beta blockers with dr. wanda filer, president of the american academy of family physicians.

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ROB KNOPPER: let’s just get straight into it. beta blockers for musicians are a colossal topic, and few dare to address it. 

there are two sides to the story: we deal with these intense fight or flight nerves during auditions that prevent us from playing our best. beta blockers, in some cases, have the power to literally change our lives and allow us to translate our musical life into a career. they can be a tool to help us leap over some of the symptoms from nerves. but then there’s historically been a very serious stigma surrounding them. they’re considered by some to be a performance enhancing drug. they’re banned in some professional sports. so we continue to ask ourselves (and each other): is taking beta blockers cheating?  

but i knew that i had to find a way to address them. i wanted to find out some deeper truths about them for myself, but also for my audience. and to give you an idea of how important this is to musicians taking auditions, i’ll tell you what just happened. three hours ago, i asked my audience on facebook if they had any questions or thoughts about beta blockers that i could bring to the interview. they responded with a flurry like i’ve never seen. it caused 45 comments in three hours. editor’s note: there were over 70 comments that day. not only that, but the most frequently expressed audition struggle by far is audition nerves and performance anxiety. people are hungry to learn more about beta blockers.  

WANDA FILER: wow. did you say 3 hours? 

RK: it’s a really personal topic for people, it’s a hot button issue. 

and it’s something that people don’t feel comfortable sometimes being open about. when i was a student, i didn’t know what to do. i didn’t know whether it was ok or how to do it right. so i wanted to provide those musicians with some kind of guidance or information. but i can’t just give it to them on my own, because i’m not a doctor and that would be irresponsible of me. which is why we have so much to learn from you. first of all: you’re a physician? 

WF: yes, i’m a family physician. 

RK: and you’ve prescribed beta blockers before? 

WF: yes, all the time. they’re very common. typically we use them for blood pressure control. we’ll also sometimes use them for people with heart disease or for people who have had heart attacks, because there's evidence to show that taking a dose of the beta blocker can lower your death rate after a heart attack. 

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enroll in my new online mini-course, called how to advance in an orchestra audition 101. it's totally free, and it will be delivered straight to your email.

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RK: i see. so are blood pressure control, heart disease and heart attacks the main purposes of beta blockers? 

WF: that’s right. with that said, there are other reasons. i certainly have patients who come in and have issues with anxiety where they get lots of palpitations, and it really interferes with their ability to function. and one of the ways to block down some of the symptoms is a beta blocker. 

beta blockers are not addicting, so it’s not a habit-forming sort of thing. however, it’s not the chief way i’d like to have people manage their anxiety. we advocate a multi-faceted approach that helps people learn to handle their anxiety. but in the short term, a beta blocker can be a way to block some of the negative symptoms. i will have people who occasionally need something for a particular event, like if they’re going to give a speech, if they’re going to go on an airplane, or if they’re going to do a performance. but it’s not something that we recommend for people to do on a regular basis. but, if they’re a generally healthy person, beta blockers are usually pretty well tolerated in low doses. 

RK: so when you prescribe beta blockers for anxiety, it’s at low doses, and only occasionally. and how often would you say occasionally is? 

WF: good question. it depends on the person. if they’re finding that they need beta blockers every day, then i’d like to help them find another way to manage that anxiety. and that’s a whole series of things. that might be something we’d call cognitive behavioral therapy, which includes relaxation techniques and some biofeedback. cognitive behavioral therapy (cbt) is a way to kind of reframe thought processes relating to your anxiety. we use it for people with stress, depression or anxiety. it helps you to think differently and to learn to think differently about the stress that you’re walking into. and you learn new strategies for coping with that stress along the way. another thing that i tell people is to think about getting a reasonable amount of exercise. aerobic exercise is where you can work out a lot of your background stress. and then consider things like tai chi, which is a slow chinese exercise, or yoga. in a lot of cases people have a lot of underlying background stress, and when you put some sort of an event on top of that, it just pushes them over the edge. so a good strategy is to try to lower their stress response in general and have them learn new ways to manage the remaining stress.  

RK: it sounds like you’re saying there’s sort of different levels of anxiety that would be treated in different ways. 

WF: yes. 

RK: is performance anxiety a mental illness? 

WF: let me clarify. there is a diagnostic condition when people have what we call generalized anxiety disorder. that’s different than feeling anxious because you’re going to do an audition or a performance, but the rest of the time you’re functioning totally fine. but there are people who have background anxiety that keeps them from leaving their house. or it keeps them from functioning as they want to function, or maybe it gives them a lot of difficult symptoms day to day. that generalized anxiety disorder can be really limiting in terms of being able to get out and do their activities. and there are many ways to treat that, but the beta blocker, in that situation, is not my first choice. there are other prescription medications we typically use for that. beta blockers are something that we can use off and on, but again, it would not be the first line of therapy. the anxiety that you’re talking about sounds like it’s more of a performance anxiety. 

RK: exactly. so when treating performance anxiety, would you say that beta blockers are kind of a last resort after a bunch of these other things that you’re mentioning, like CBT, tai chi, yoga, and exercise?  

WF: i don’t know if i’d say that they’re a last resort. again, it comes down to the frequency and the severity of the performance anxiety. it's a conversation that i would encourage your colleagues and students to talk to their family physician about. because there may be other things that can lessen their need for the beta blocker. and the beta blocker might just be a short term strategy. remember that beta blockers aren't only prescribed for performance anxiety for musicians. there are other activities where a tremor can be really debilitating, like for snipers or people who are in competitive sports. public speakers will sometimes use a beta blocker to block the rapid heartbeat and the tremor that pops up in their hands and their voice. so your music colleagues are not alone in looking for something to help calm anxiety but also potentially protect their performance. this goes beyond the music industry, and i think that’s important to know. 

RK: so how many types of careers have you prescribed beta blockers for performance anxiety? 

WF: well, i don’t live in new york, and it’s not a common request that i get in pennsylvania. but i do get people who will be doing a big speech like a commencement address, or they’re walking their child down the aisle for a wedding. and they don’t want to be given something like a valium that’s going to knock them on their butt where they’re very sedated. they want something that’s going to allow them to be functional and get them through this event. that’s a situation we’ll use beta blockers as a one-off. 

RK: ok. so, say i’m a sophomore in college, i just took an audition after practicing for 2 months, my hands were shaking so i couldn’t control my small muscle movements and i lost the audition. should i try beta blockers? 

WF: i think it depends on a conversation with your personal physician. it might be reasonable for you to do it occasionally. but i think it’s important to remember that if you’re a sophomore in college, you can have anxiety no matter what field you're in. you might be a medical student going in to do your oral exam, and that anxiety puts you in the bathroom with diarrhea, or causes you to have heartbeat and tremors in your voice. we all go through that in our careers. it’s not unique to the music community. part of your professional growth is learning other ways to manage that anxiety and reframe it. cognitive behavioral therapy can be helpful in this case, for instance, to reframe it as something that's energizing as opposed to debilitating.  

i think there’s a fine line between using the medication to get you through this one time versus something that you get dependent on, rather than giving yourself the opportunity to grow and learn from your anxiety in order to manage it. and that’s across all fields, not just music. if it’s your first time doing something on your own with somebody watching you, your hands are going to shake. part of professional development is learning how to manage stress. and part of learning to grow, personally and professionally, is the willingness to say, "i didn’t win this one, but maybe i’ll get the next audition."   

there are people for whom i would really not recommend for the most part that they use a beta blocker, like someone with asthma, which is a very common disorder. or people who have underlying heart problems. and that’s more common than you might think. slowing their heart rate down creates significant issues for them. so before you reach for a beta blocker, i think it’s important to talk to your family physician. your family physician is someone who knows you, who knows your past medical history and what your risk factors are, and says, "yes you’re clear for this." and they also might have some ideas of other ways to manage this.  

i’ll give you an example. you talked about a sophomore college student. as an example, beta blockers tend to lower your blood pressure. blood pressure control is one of the classic things we use them for. most younger performers will tend to have lower blood pressure anyway by of virtue of their age. they frequently may have a blood pressure that’s 90 over 60, which is a low reading, but since they’re young that’s totally normal for them. if you layer a beta blocker on there, the next thing you know you’ve got a person who’s weak, dizzy, and feels like they’re going to pass out. the unintended consequences are also something to just keep in mind.  

RK: what can happen if your blood pressure is too low? 

WF: you lose consciousness.  

RK: and that doesn’t do well in an audition. 

WF: exactly. or driving to an audition, or even being on a bus or subway trying to get there. you can also feel incredibly fatigued before you get to that point and maybe not as mentally sharp. that's not something you want to experience in any kind of an audition. so i think there’s pros and cons to doing this. and again, it’s helpful to evaluate each person’s situation individually. this might be fine as a one time thing if your doctor has blessed it and said that your blood pressure can handle this because you don’t have any counter indications (reasons not to use it). say there’s a one time big event - you’re going to audition for the metropolitan opera as a percussionist - then maybe your family physician thinks it’s fine. but you don’t want to be in the habit for every performance. because eventually you need to find a comfort level as a professional with doing your job. and remember that a little bit of that anxiety can also be your leg up, or your edge, that helps you actually improve your performance.  

RK: so would you categorically say that this shouldn’t be something that people end up taking before every rehearsal and performance? 

WF: i would not recommend that.  

RK: is it pretty dangerous to do that? 

WF: it’s hard to say. it’s hard to make a categorical statement of whether it’s dangerous. there are certainly people for whom it is dangerous. whenever you reach for a pill as your solution to something every time, i worry about that tendency. because you’re not giving yourself the opportunity to really face the issue, which is: how can we better manage your anxiety, and how can you professionally and personally grow? you’re looking for a quick and easy fix. and that’s the tendency that tends to get people in trouble.  

RK: that personality trait that can lead you in the wrong direction. 

WF: yeah, because what’s the next thing you're going to reach for? and to be honest with you, going through this stress is part of learning. we’ve all been through it, regardless of our profession. when you’re working to achieve something stellar in your performance in any line of work, that stress and anxiety level can help to motivate you and to help to get to that next stage in your career. and you learn a lot about yourself along the way. and so reaching for a pill, repeatedly, really would alarm me that it’s a person who’s struggling with their identity in that career. 

RK: let’s switch gears for a moment. what’s the actual functionality of beta blockers, in layman’s (musician’s) terms? 

WF: well, inside your blood vessels you have what we call receptors. and there’s different kinds - alpha receptors and beta receptors. they both have different impacts on your body. and so what a beta blocker does is it blocks the beta receptors. and to make it more confusing, there is more than one kind of beta receptors: beta-1 and beta-2. in terms of beta blockers, certain kinds block both kinds of beta receptors, and other kinds block one specific beta receptor. propranolol, otherwise known as inderal, blocks both. but generally what they will do is they will slow your heart rate down. they also tend to lower your blood pressure a little bit. for some people who are a little tremulous, it might take that down a notch. it might block the palpitations a little bit. those palpitations, by the way, can be brought on by caffeine and nicotine. if you’re someone who’s got a lot of caffeine and nicotine in your system, pulling that back out of your body is probably going to work just as well as taking a beta blocker. 

RK: so going off nicotine or caffeine can have a similar effect to a beta blocker? 

WF: yes, and if we get you off nicotine long term, that’d be ideal. and people who are really pushing back a lot of caffeinated drinks are going to get a tremor right off the bat. that tends to kick up your heart rate and it may make your hands shake a little bit more. and so looking for other alternatives to the beta blocker would be beneficial. 

but generally a beta blocker will lower your heart rate for as long as that pill is working in your system. that can be 12 hours, or it might be 24 hours. and they tend to make you a little bit more fatigued. some people read that as mellow, but a lot of people will take it and get really tired. and again, if your blood pressure is normally a low, normal, young adult blood pressure and suddenly we drop you 10 points with a beta blocker, you may not feel so hot.  

RK: is it a bad idea to pair beta blockers with coffee? 

WF: well generally it’s not great in terms of wellness. you’ve got caffeine that’s out there driving your body hard, and then you have a beta blocker which is trying to put the brakes on. that’s not generally a strategy we’d like to put your body through - they’re at cross purposes. the better way to approach it would be to limit your caffeine if you know you’re going to do a performance. some people need a little bit to keep that edge, but that’s probably not the person who’s going to be using the beta blocker. that’s the person who thrives a little bit on having that energy boost. but again, i usually say to people that if anxiety is really becoming an issue for that upcoming event, think about things like tai chi. think about things like yoga or learn to do some mindfulness techniques where you can achieve centeredness. those activities can lead to a very beneficial effect because your brain can control a lot of your body’s stress and anxiety at least as well as beta blockers are going to do. 

RK: what kind of chemical effects can things like yoga and tai chi have on your brain?  

WF: they’re very calming. they tend to lower blood pressure. they lower anxiety levels. a lot of people generally have a much stronger self-reported sense of wellness. the other thing is it improves agility and it decreases risk of falling. there’s a lot of science coming around now in terms of brain health around what we call mindfulness. the thought process and exercises involved with tai chi and yoga can help you better control your body’s own response under duress. the people who have that sense of wellness improve and the anxiety often lessens. and even your ability to take on more complex tasks, like in the audition, becomes easier because you have a little more control of your body’s own functions. 

RK: in a way, those exercises are preventing nerves or anxiety from ever popping up… 

WF: …or from from firing off. and even if it does, it’s probably not as much. and you’re also more attuned to say, hey my heart’s racing, wait a minute - i know what’s going on here. i’m nervous. let me take 30 seconds and calm myself down. and you take 30 seconds to take some deep breaths and close your eyes, and you go to your happy space that you’ve been taught to do with yoga and tai chi. maybe you do a quick couple of stretching exercises, and the next thing you know all of that has passed. and you don’t have the fatigue or the low blood pressure that the beta blocker might leave behind. 

RK: so if you do end up trying and using beta blockers and they successfully deal with whatever it is that you’re experiencing, do you think of them sort of like training wheels? meaning: over time you ease up on them. you take them for auditions with lower and lower dosages until you can phase them out completely? 

WF: well, i like that analogy. in the best case scenario if you’re going to use the beta blocker, the hope is that it wouldn’t become a standard thing for every audition. and hopefully most of your auditions you could do without the beta blocker. and you’re working towards the goal of not needing it at all. 

RK: when i talk to students about nerves and stress and anxiety, i sometimes give them this metaphor: performance anxiety is like getting a cold. there’s a cause of the cold, and then there are effects or symptoms of the cold. you can try to prevent the cold beforehand by wearing a coat outside or washing your hands a lot. but once you have the cold, you have to treat the symptoms by drinking a lot of water or sucking on a cough drop. if things like fear of failure are causes of nerves, are beta blockers a way to treat the symptoms of nerves? 

WF: basically yes, but they’re not going to treat all of the symptoms. but they may minimize some of the symptoms. 

speaking of causes, that brings up another issue, which is being well-prepared. that’s going to have an effect in your line of work along with other professions. have you done your pre-work? have you done your warmup? in my case, have i studied for my test? have i done my anatomy evaluations? as a family physician, we have to re-take our boards every few years, and if we don’t pass then we don’t stay in that profession. and so that’s anxiety-producing. a lot of it comes down to how you prep for it and how you get yourself ready. 

i'll tell you again: i am concerned about the tendency to say, “let’s go to a pill” to always block the symptoms. because very frequently your body’s response may be really beneficial to your performance. and on the flip side this beta blocker may make your performance flatter because you don’t have that edge. and so it’s a fine line between if you help yourself or if you hurt yourself by reaching for this medication. and to go back to your common cold analogy, we frequently say to people now that constant cold medications are not recommended at all for children, because they have some really negative reactions. there are people for whom a beta blocker has significant risk, and we know that people tend to overtreat. and we’re not helping ourselves if we overtreat.  

RK: are you even more hesitant to prescribe beta blockers than most other drugs initially? or is it just all medication that you wouldn’t want to liberally hand out to people? 

WF: i would say it’s the latter. i don’t think i have any more concern about beta blockers than other drugs. they have been around for a long time. for most people, they are generally safe, and we use them a lot. but we use them for blood pressure and heart disease predominantly. sometimes also to block out recurrent migraines. but we try not to give people any medicine if there’s not a very good need for it. because this tendency to medicalize life in general is not always healthy. and it’s not a healthy trend, psychologically and physically, to reach for a pill and say, “hey, this is a quick, easy and convenient way to block it.” part of your professional growth is learning to cope with anxiety. i think that if you’re using one dose every few months, for some big event, then i don’t have as much of a concern if you're basically healthy. but for someone who’s doing this every day, or even a few times a week, there are probably other techniques you want to investigate to help you get your anxiety under better control.  

RK: yeah. i’m so glad you keep bringing it back to the preparation and the lifestyle rather than the quick fix of medicine. i’m totally on board with that. most people aren’t prepared enough in the first place and then it’s no surprise that they get nervous that their audition isn’t going to go well. 

WF: and that may or may not have anything to do with the beta blocker. and the other thing is that when you have a failure, you have a chance to learn from that and say, what could i do differently for the next one? the failure is the growth opportunity for all of us. and all of us in every profession or career are put in that circumstance. so thinking that you’re alone in this is probably more distructive than realizing that everyone goes through this. this is all part of the growth opportunity.  

RK: i’m jumping around in my questions, but i’ve been dying to hear your thoughts on this one. some people say that beta blockers are performance enhancing drugs and they’re cheating. they point to the fact that even though they’re not illegal in music, they’re illegal in some professional sports. what do you think about that? 

WF: i don’t think i have an opinion either way as to whether in music it’s cheating. i think that’s something that the discipline of music has to decide. that’s a kind of an ethical question. i think the bigger concern that i have is in the health of the individual musician. i want to try to help them understand that it’s ok to be nervous, it’s normal to be nervous, and it’s even normal to be incredibly nervous. learning and channeling that in a way that helps you grow as a person is, i think, is a much better path to success.  

RK: why do you think they’re banned in like baseball, for instance?  

WF: i think the concern is: does it create an uneven playing field? and the reality is, again, the whole mentality of reaching for a pill for an answer, and that’s not healthy.  

RK: if you’re prescribed beta blockers and it doesn’t work the first time, does that mean that it doesn’t work for you period or does it take a few tries to become effective? 

WF: most of the time i would think the first dose is going to work if it’s ever going to work. the issue might be that the dose is not the right amount. for instance, if you’re a big person, you might need a little bit different dose than if you’re a skinny person. if you’re younger you might metabolize faster than an older person. so there’s a lot of different individual factors that come into play. i wouldn't make my decision based on the first try. but if you and your doctor have decided that you’re going to give this a try and it doesn’t seem to work after one time, you could try again at your next big performance. but if it doesn’t work after the 2nd time, i’d put a call back into your doctor and say, "this doesn’t seem to have the effect - what are your thoughts on that?" 

they may decide to change the dose. more commonly, they’ll hopefully work with you to figure out some other way to manage the pre-audition anxiety and jitters. and you might layer on tai chi, yoga, and all that relaxation stuff to the beta blocker. hopefully we’re going to do all that stuff first before we resort to a pill. 

RK: i see people doing yoga in the practice rooms and intermissions of shows at the met opera. it’s definitely helpful for musicians and is catching on.  

WF: that’s great to hear. and i’ll tell you that i think tai chi gets underestimated. it requires a little bit more space because you move, but it’s also a really good group thing. is there a way that you can do this as a group when you’re all getting ready to audition? it takes 20 minutes and it also builds camaraderie as a group. (editor’s note: looking at you for this, schools!) 

RK: our audition times are hard to predict, and sometimes we have to be ready to perform at all different times of day. for instance, you might have a prelim round at 9am, a semi-final round at 4 pm. but you might not know if you’ve made it to the semi-final round until 1pm. it’s different for every audition scenario. how long before the actual moment should you take it? and then if you have to play again later, when should you take that second one? and should you only take a partial dosage for the second one? is that even safe? 

WF: first of all, i would encourage you to definitely get your medications through a legitimate source. make sure your medications are coming through a physician and that it’s not under the table and you’re not borrowing it from somebody. besides the fact that it’s illegal, i worry about what you’re actually getting and what else is actually in there. 

in terms of how far in advance before the event to take the beta blocker, It depends on what formulation you use. you need to ask your family physician or pharmacist. This is called "onset of action" and some medications will kick in with 20-30 minutes but others could take a couple hours. Then slower onset ones tend to last longer in your system.

there are different lengths of duration of the medication. some of them are 12 hours and some are 24 hours. so it depends on what your physician prescribes for you. but once you’ve taken it, you’ve taken it. i wouldn’t keep taking them. if you start to take extra, the only thing you’re going to do is potentially put yourself at greater risk for the fatigue, the low blood pressure, and the downsides. you’re not going to get a lot of upsides. my guess is that if you keep going up and up then you’re going to significantly hurt your performance. 

RK: right. taking the spark out of playing. 

WF: exactly. taking a dose a few hours later... it just doesn’t work that way. and if this is what you’re thinking about, i have to keep going back to the part of me that is hopeful that you’re finding other ways to manage your stress.  

RK: just kind of a specific questions about the pills - how old is too old to take the pills? do they expire? 

WF: oh, you mean the age of the pill. usually there’s an expiration date that is somewhere on the bottle. now, when i write a prescription - i think this is true in every state but i’m not sure about that - the prescription is usually good for a year. but the pills themselves honestly are better a little longer than that. but if you’re looking at one that’s several years old, that’s too old, for a few reasons. first of all, your health may have changed between the time it was prescribed and now that you’ve decided to take it. if it’s been a while since you’ve had a checkup and talked to your healthcare provider about this, it’s probably better to talk to them first. even by phone call. sometimes it’s enough to run it by a nurse over the phone, but a lot of times i’d like to check the blood pressure and make sure you haven’t developed something else. so if you’ve been sitting on this medicine for 4 or 5 years, i probably wouldn’t take it. not so much that i think it would be harmful, it’s just not going to work. and the other thing is just if you haven’t needed it in that period of time, i’m not sure why you would need it now. 

RK: will the actual effectiveness of the pill be lower if it’s old? 

WF: yes. 

RK: and your health might have changed so a doctor needs to have oversight? 

WF: we hesitate to use the word oversight, but they need to be on your team. you need to have someone that you have a relationship with because this isn’t your only health issue. there’s other things you need to be talking to them about to keep yourself healthy as a peak performer. and that’s what they’re there to do. this is one part of the bigger picture of who you are as a professional musician.  

RK: are there foods that contain natural beta blockers? 

WF: that’s a good question. not that i’m aware of. there are certain herbal products that people will say are relaxing or sedating, but i am not an expert on this by a long-shot. i’ve had patients use them to try to help them sleep. but i’m not sure that’s what you're going to want to do before you perform. some people will drink milk because it has a certain amino acid in it that can help you relax. but again, that tends to be more of a relaxing, sedating kind of thing. turkey has triptopham - that’s another one. but i don’t have the knowledge to know how that’s going to impact performance.  

RK: are those specifically targeted at those beta receptors that you were talking about? 

WF: no. off the top of my head, i can’t think of any food products that would do that.  

RK: one of the articles your secretary send me was about beta blockers for heart problems. and the 3 different medications were atenolol, metoprolol, and propranolol. i’m used to propranolol. are the other ones also used for performance anxiety? 

WF: it depends on the person, and it depends on the physician. that’s why i mentioned that some of them are beta-1 and beta-2. some of them we would use more for people who have asthma. it might be a little cleaner. propranolol is one of those that blocks both beta-1 and beta-2, so if i have a person with asthma and they try to use their inhaler, and they’re on a beta blocker, there’s a chance that their inhaler’s not going to work very well. so it’s the nuances, if you will, amongst them. and propranolol you can get a shorter acting or a 24-hour version. same for metoprolol and atenolol. they work differently across beta-1 and beta-2 receptors.  

RK: i see, so should we think about atenolol or metoprolol for performance anxiety? 

WF: those drugs are almost entirely used for high blood pressure (hypertension). they’re for beta-1. for performance anxiety, i would think a lot of people would use propranolol, but i certainly have patients who try metoprolol with fairly decent results. but it’s not something we want people to do all the time.  

RK: actually, someone asked about asthma specifically. are beta blockers dangerous for people with asthma? and are there other conditions that mean you shouldn’t use beta blockers? 

WF: asthma is one of those things where we’re cautious when we give beta blockers to people. you want to make sure that you’re under physician guidance. because even one dose can make the person more short of breath and trigger some problems. so that is very clearly a person who needs to be talking to their physician. there are an awful lot of people out there who are coughing and wheezing, and they have not been told they have asthma. and so a beta blocker could worsen those symptoms because they may have an undiagnosed disease that frankly should be seen. we should be seeing them because we could keep their lung disease from getting worse if we give them the right medication. the beta blocker may actually worsen the scenario for them. 

another condition affected by beta blockers is people with certain underlying heart rhythm issues that they may not even be aware of. a beta blocker, which slows down your heart rate, can sometimes make it better, and sometimes make it worse. and so if they know they’ve got it, like if they’ve got a pacemaker in, which is more common than you might think including in younger people, i would definitely want to talk to your doctor before you try a beta blocker. or if you or anyone in your family have had any kind of a rhythm abnormality or even sudden cardiac death, you want to talk to somebody who knows you who can evaluate you before you do this. if you have an uncle who dropped over dead at 30 on a basketball court, you probably want to talk to your physician before you decide you’re going to take one of these. 

finally, one of the groups that i would caution about is people who are diabetic. a beta blocker can block their awareness of when their sugars start to drop. and so the next thing you know their sugars drop to dangerous levels and they’ve blocked a lot of their symptoms to warn them, and that can be life-threatening.  

RK: got it. say that you’re taking them, and at first it was a relatively healthy, occasional, every once in a while thing. and then you let it spiral out of control and start taking it regularly for every orchestra rehearsal, performance, recital, audition, etc. what would happen to you if you do that over time?  

WF: if you keep taking it longer term, you’re lowering your blood pressure. if your blood pressure can handle it, it’s fine. you’re not going to create a disease for yourself, for the most part. but again, i’d go back to the issue of reaching for a pill as your solution, which is not a particularly healthy long-term approach. and if you are simply using this to avoid doing the hard work of learning from your experience, and growing as a performer and using this to block the symptoms, i don’t think you’re necessarily helping yourself. will you get a physical illness because you’re taking lots of beta blockers? probably not. but you need to be in touch with a physician if you’re using these medications regularly, especially if you’ve got something that’s cropping up along the way. somebody needs to be working with you on your team on this. and i can’t overestimate the importance of figuring out a way to manage your anxiety without medication. 

RK: yeah, i wanted to see if i could find a way to scare people out of deciding that they should take it all the time, which is why i asked that question. 

WF: i think what would scare me, as a physician, is whenever you see a patient who reaches for a chemical cure or a chemical way out of their problems without looking at the alternatives. particularly when it’s something like performance anxiety. if it’s somebody who cannot leave their house because they’ve got such agoraphobia, then maybe medication is absolutely necessary. but if this is a performance anxiety thing then there are other ways to manage this beyond a pill. and that tendency can be sabotaging your personal growth. and if this doesn’t work, what are you going to do? reach for the next thing? and the next thing is addicting. and the next thing is going to put you in really bad situations, long term. so, as i said: once in a blue moon for a beta blocker if you’re otherwise healthy is probably fine. but as a repeated behavior, i cannot in good faith recommend that. 

RK: if you do have that one big audition coming up, and you’re going to try beta blockers, should you try it in advance as a practice for a mock audition or something like that? 

WF: it’s probably not a bad idea. again, though, i would talk to your physician before you do that, because i want your blood pressure checked first. if you’re doing that on the day that you’re going to be driving and we drop your blood pressure and you have a car accident, then i haven’t helped you. before you even take the first pill i would talk to your physician. not your friend. talk to your family doctor who knows you. they can check your blood pressure, they know whether you have asthma, and they can give you some guidance. and sometimes they may say no. they’re not saying no to be mean or to make you suffer, they’re saying no because their goal is to do no harm. and i would hope that, per your student, their goal is to not harm their health or their career. 

RK: i’m looking over my questions here and i think we covered just a ton of amazing stuff. one last thing. if you’d have the opportunity to say something about beta blockers to a large population of student musicians, what else would you tell them? 

WF: i think the one thing is to recognize that they’re not alone in experiencing this. it’s to try to get over that sense of guilt... that sense of, "hey, it’s only me." every one of your fellow students is experiencing the same thing. and if they’re not, they’re lying. and if you can find a way, as a student, to not only lift your own sense of wellness and well-being, but to also do so for your fellow student through an open, honest conversation of a healthier way to manage the stress of a performance, then you’ve done a great service not only for yourself but for your discipline.  

i think that a beta blocker maybe once or twice is fine. if you think about the first time you’re going to do an open heart surgery, you don’t want your hands shaking either. and of course you’d have already gone through the advanced preparation procedures. but it’s scary. and regardless of what career you’re going into, the nerves and the anxiety are part of the journey you go through. and for most professionals, it does pass over time because you realize that if it’s not this audition it’s the next one. and yes, this is a really big audition, but the next one is no less valuable. and that part of learning that about yourself is really an important part of professional growth.  

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