see: Music and Medicine on Monday (M+M+M) at the University of Iowa - Schedule of Events and Disclaimer
and: Performance Anxiety for Musicians Part 1: Nonmedical Management
Use of Propranolol (Inderal) Allowed Me to Pursue My Dream to Be a Musician (2 minute 11 seconds)
Discussion of Medical Therapy of Anxiety with Performance (31 minutes 27 seconds)
Definitions
Performance Anxiety - persistent fear in situations when under scrutiny or evaluation including musical performance and public speaking. It is classified in the Diagnostic and Statical Manul of Mental Disorders (DSM-5-TR) as a subset specific to performance within the more general social anxiety disorder (Szuhany 2022, Gers 2025, Association 2013).
Background
Anxiety disorders reported by Szuhany and Simon (2022) to affect ~ 12.7% of the US population with a lifetime prevalence of 34%. These authors report identify subsets to include a lifetime prevalence of Social Anxiety Disorder (13%), Generalized Anxiety Disorder (6.2%), Panic Disorder (5.2%) and Agoraphobia (2.6%).
Brugués (1) reported in 2011 a review of 16 articles addressing Music Performance Anxiety (MPA) to identified a transition from early childhood when performance anxiety is rare to adolescence when symptoms are present in a manner similar to adults. The capacity for self-evaluation (self-criticism) as it emerges in middle to late adolescence it thought to contribute to MPA.
Lockwood (1989) reported that 27% of the orchestral musicians surveyed used propranolol to manage their anxiety prior to a performance with 19% of them using it daily
Review of drug interventions for MPA (accumulated by Brugués (2) in 2011) catalogued responses to propranolol, captopril, oxazepam, atenolol, oxazeparin, oxprenolol, terbutaline, pindolol, nadolol to conclude that 'β-blockade reduces some of the physiological symptoms of performance anxiety'. They identify that 'the drugs should be used only occasionally: and along with 'psychological therapies'.
A more contemporary review through cross sectional survey by Kuwabara et al (2024) evaluated 311 musicians (40% full-time ensemble musicians) to identify performance was enhanced with beta blockers (32%), benzodiazepines (22%) and cannabis (17%). In this study, a majority of the group (57%) identified they take beta-blockers when auditioning for a job with 51% taking them for performance
Beta Blockers for Musician Performance Anxiety
Lockwood (1989) identified performance anxiety as syndrome characterized by "nervousness, fear, tremors, tachycardia, shortness of breath or 'tight' breathing sweaty palms, dryness of the mouth, nausea and an urge to micturate" He correlated these symptoms to excessive adrenergic tone and identified use of beta-adrenergic-blocking agents as extremely effective int he prevention of these symptoms to conclude they 'are clearly indicated in the management of severe performance anxiety' and 'may be the only treatment necessary"
Fernholz et al through literature review in 2019 reported overall support for benefit from use of β-Blockers on anxiety but concluded that "although they reduced the physiological symptoms of MPA, such as heart rate and tremor, but anxiety, negative cognitions and behaviour were not affected".
Research Addressing Beta Blockers and Surgical Performance
- "Propranolol, 40 mg, administered 1 hour prior to surgery, significantly decreases tremor and anxiety in the surgeon without untoward effects to the surgeon' as per. Elman et al (1998). A blinded crossover study of propranolol (40 mg) taken orally 1 hour before performing surgery versus placebo in 5 third-year ophthalmology residents over a 10 week period permitted judging or anxiety and tremor while placing the first three sutures fllowing lens extraction. These investigators identified that propranolol significantly decreases anxiety 'without impairing higher central nervous system functions" - identifying that alcohol and benzodiazepine drugs in this surgical setting would be impractical and unethical. The discussion also introduces the potential use of more rapid acting sublingual Timolol as a beta-blocker.
- Through use of a vitreoretinal surgical training simulator that scores performance, Roizenblatt et al (2020) identified through study of 15 novice ophthalmology surgeons that performance "was worse after receiving low-dose caffeine alone but improved after receiving low-dose propranolol alone. Their performance after receiving propranolol alone was better than after the combination of propranolol and caffeine." The performance was interpreted to reflect hand steadiness and dexterity.
References
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Elman MJ, Sugar J, Fiscella R, Deutsch TA, Noth J, Nyberg M, Packo K, Anderson RJ. The effect of propranolol versus placebo on resident surgical performance. Trans Am Ophthalmol Soc. 1998;96:283-91; discussion 291-4. PMID: 10360293; PMCID: PMC1298399.
Humayun MU, Rader RS, Pieramici DJ, Awh CC, de Juan E Jr. Quantitative measurement of the effects of caffeine and propranolol on surgeon hand tremor. Arch Ophthalmol. 1997 Mar;115(3):371-4. doi: 10.1001/archopht.1997.01100150373010. PMID: 9076210.
Roizenblatt M, Dias Gomes Barrios Marin V, Grupenmacher AT, Muralha F, Faber J, Jiramongkolchai K, Gehlbach PL, Farah ME, Belfort R Jr, Maia M. Association of Weight-Adjusted Caffeine and β-Blocker Use With Ophthalmology Fellow Performance During Simulated Vitreoretinal Microsurgery. JAMA Ophthalmol. 2020 Aug 1;138(8):819-825. doi: 10.1001/jamaophthalmol.2020.1971. PMID: 32525517; PMCID: PMC7290718.
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