MUSICIANS’ HEALTH Performance anxiety can range from an occasional crisis to a reason for changing PERFORMANCE careers. Physicians and sports psychologists—and insightful ANXIETY AND music teachers—have helped artists transcend, harness, or HOW TO BEAT IT just leave the shakes behind. Here’s a psychiatrist’s hen I first met Lisa, have much to do with actual artistic analysis of the syndrome— a talented pianist skill or knowledge. It has hobbled the and a recipe for the cure. in her second year pre-eminent as well as the novice. It is at a prestigious an equal-opportunity anxiety that doesn’t by RICHARD A. conservatory, she discriminate. FRIEDMAN, M.D. sat down in my Vladimir Horowitz, Maria Callas, Sergei officeW and burst into tears. “I knew that Rachmaninoff, and even the great Chopin Bach cold and don’t know what happened were all said to have been plagued by to me.” performance anxiety. The legendary actor At 18, Lisa was no stranger to perfor- Laurence Olivier said in an interview on mance—she’d been playing for audiences, 60 Minutes that well into middle-age, whether friends, family, or perfect when he was at the apogee of his career, strangers since she was six. Over the past he reached a point where he could not several months, she had worked hard on a go out on stage because of paralyzing Beethoven Sonata, the Brahms Handel anxiety. During a run of Othello, he once Variations, and a Bach Partita. “I could asked a fellow actor to stand in the wings have played this in my sleep,” she said. during a soliloquy so that he didn’t feel I was sure she could have, but during so alone on stage. her recital something alarming had hap- What, exactly, are performers with this pened: she felt unaccountably nervous anxiety so fearful of? What danger lurks a few hours before the performance and, in the audience that could provoke such as it drew near, she became aware of a panic and dread? Very little, in reality. sense of dread. She had no idea what she Performance anxiety is fundamentally was anxious about—after all, she could a hard-wired fight-or-flight response play it all flawlessly in the studio—but that we share with virtually all other when she finally walked out on stage animals and that evolved over millions and looked out at the audience, she of years to protect us from life-threat- might as well have come face to face ening dangers. Faced with a potential with a lion. Her heart raced, her mouth predator or feared enemy, we get a surge was cotton-dry and she felt tremulous. of adrenaline and the stress hormone Worst of all, her hands felt rubbery. cortisol. Our heart rate spikes, our mus- Welcome to performance anxiety, a cles are supercharged and we are ready very common anxiety response that has to flee—or fight. It is a marvelous feat afflicted performers of all levels and of evolutionary engineering that saved ages ever since humans invented the our ancestors from saber-toothed tigers ritual of artistic performance. As you and the like. The problem is that we are have already guessed, it doesn’t really still hard-wired for high-risk life in a 95 MUSICIANS’ HEALTH world that, for most of us, no longer exists. percent of the nearly two thousand musi- are several others. All block the adrenaline Ask people with performance anxiety cians surveyed reported that performance receptors in the body, preventing rapid what they fear and they will tell you that anxiety was a serious problem for them. heart rate, sweaty palms, dry mouth, and they worry they will humiliate or embar- But many smaller studies done in the past tremulousness. These drugs generally do rass themselves in front of other people. It few years show higher rates of performance not make a person feel calmer at baseline, doesn’t take much imagination to see that anxiety among musicians, in the range of but kick in when a person is stressed. Beta- the experience of being intensely scruti- 40 to 50 percent. Not surprisingly, subjects blockers are also used to treat high blood nized is exactly what prey experience— indicated that they were more distressed pressure and cardiac arrhythmias, though just before a predator pounces and makes giving solo performance than when playing at much higher dosages than we use for dinner of them. In other words, people with chamber music. performance anxiety. In low doses, these performance anxiety are reacting as if they Performance anxiety is not a universal drugs rarely have adverse side-effects. But were still living on the savanna facing a experience. As with other anxiety states that doesn’t mean you should take your mortal threat, when they are simply on (such as panic attacks and social phobia), friend’s medication. It should be prescribed stage facing a group of largely harmless genetic factors increase susceptibility. by a physician who knows your medical strangers. Sure, there might be the occa- Some people are temperamentally more history and has examined you to be sure sional critic sharpening his knife in the reactive than others and are hard-wired to that these usually safe drugs do not cause audience, but there is little mortal risk to be more socially anxious. Developmental a problem for you. For example, some peo- performing. This is not to say that the stakes and psychological factors play a role as ple with very low heart rates or low blood aren’t high for musicians in today’s super- well. It is not hard to imagine how overly pressure can still take low-dose beta- competitive environment. Of course they are, critical or perfectionistic parents or teachers blockers, but their blood pressure needs but musicians with performance anxiety might make an individual feel inhibited or to be monitored. experience disabling anxiety at every per- anxious about performing. Contrary to popular intuition, anti-anxiety formance—even when the stakes are low. Curiously, children rarely suffer from medications, such as Valium and It is not that anxiety per se is a bad performance anxiety. Young kids are typically Klonopin—so-called benzodiazepines— thing. In fact, in small doses, it is beneficial. unselfconscious and supremely confident are a very bad idea for performance anxiety. There is a well-known relationship between performers. With the teen years comes peer Sure, they will lower anxiety levels, but anxiety and performance that takes the pressure and much greater self-awareness; they are sedating and can impair reflexes shape of an inverted “U” curve. As anxiety social acceptance by one’s peer group is and motor function. You might feel calm— and arousal rise, performance of all types critically important to teens, and that gen- and give a truly bad performance. Then improves—up to a certain point. Once you erates greater social anxiety, of which you’ll really have something to worry about. reach a critical level of anxiety—and that performance anxiety is just a special type. But there is more to performance anxiety inflection point varies tremendously among What was effortless in childhood is now than just physical symptoms. Perpetuating individuals—there is a steady deterioration filtered through self-doubt. Perhaps the the anxiety is a set of negative thoughts in performance. great pianist Artur Schnabel had this in that people with performance anxiety When you are anxious, your neurons mind when he said that “Mozart is too easy commonly develop about themselves and release norepinephrine (a chemical relative for children and too difficult for artists.” the world: polarized thinking (everything of adrenaline) in your brain and this in turn Much can be done to help people who is all good or all bad); overgeneralizing enhances learning and memory. That is why suffer with performance anxiety. In the (one bad performance is equated with the we learn best when we are a little excited medical world, there are two effective person’s entire capability); catastrophizing or anxious. treatment strategies—biological and psy- (small mistakes seen as disastrous and While we all come equipped with a chological—that target different aspects career-ending); and personalizing (every- fight-or-flight reflex, performance is not of performance anxiety. thing is seen as a reflection of a person’s sufficient to set off this panic alarm in most The class of drugs known as beta-blockers self-worth, with no separation between the people. Still, it is a real problem for many can dramatically blunt the physical symptoms person and the task). This pattern can be musicians. The largest study to date, the brought about by the surge of adrenaline. changed through cognitive therapy. International Conference of Symphony and Propranolol (also called Inderal) is the most In cognitive therapy, the performer and Opera Musicians survey, found that 16 commonly used beta-blocker, though there therapist work together to examine, 96 Fall 2012 MUSICIANS’ HEALTH challenge, and correct these dysfunctional thoughts, a process that lowers the stakes of each performance and reduces anxiety MEET DON generally. But that is not all. Performance anxiety is very much like any phobia; people natu- GREENE rally want to avoid things and situations that make them anxious. It is counterin- tuitive, but the most effective treatment for Sports psychology had the time in D.C. and in Illinois as a special phobia is the very thing people want to avoid: jump on other fields in dealing investigator. Next was southern California, more of the feared situation. In other where he went on the strength of an words, exposure and desensitization.