Current p SYCHIATRY Performance anxiety: How to ease stage fright Artists may need customized medication and behavioral therapy © Doug Plummer / Photonica he violin is slippery in my grasp. I hear the T thud of my foot tapping, but the tempo feels Victoria C. Kelly, MD wrong. I’m aware of my chest pounding, a lump in Clinical house staff, department of psychiatry my throat, and heat rising from my face. Everyone is Radu V. Saveanu, MD watching me, waiting for me to make a mistake. Chairman, department of psychiatry Why can’t I stop my hand from trembling? I can only watch as the bow jumps noisily across the Ohio State University Medical Center, Columbus strings. I should have practiced more. My mind goes blank, and I miss the page turn. Silence. I blink, and the lights blind me as the applause comes, thankfully, and I exhale and run off the stage as the curtain closes. Well-known performing artists—Sir Laurence Olivier, Kim Basinger, Peter O’Toole, Richard VOL. 4, NO. 6 / JUNE 2005 25 Stage fright NORMAL VS. ABNORMAL FEAR Figure Performance anxiety is characterized by Performance anxiety features persisting, distressful apprehension overlap with other anxieties about—or actual impairment of—per- formance skills to a degree unwarrant- ed by the individual’s aptitude, training, Performance 1 anxiety and preparation. Not all performance anxiety qualifies as a mental disorder; for example, though 85% of the popula- tion experiences discomfort about public speaking,4 this anxiety does not impair most people’s ability to function. Specific Social phobia anxiety Mild to moderate anxiety is nor- mal and motivating in performances.5 However, anxiety’s effect on perfor- mance does not follow a bell-shaped curve, wherein moderate anxiety pro- Panic and other motes optimal performance.6 Instead, anxiety disorders a catastrophic model is more accurate: increasing anxiety is helpful until a certain threshold is reached, then Performance anxiety is not easy to categorize. It is situational performance plunges.7 anxiety that occurs in a public context and overlaps with but Diagnostic criteria. DSM-IV-TR does not entirely match diagnostic criteria for specific phobia, describes performance anxiety as a social anxiety, or panic disorder and generalized anxiety. form of social phobia (or social anxiety disorder) characterized by marked and persistent fear of social or Burton, Barbra Streisand, and Luciano Pavarotti performance situations in which embarrassment —have described bouts with acute stage fright. or humiliation might occur. Approximately 13% Performance anxiety can occur with acting, of adults experience social phobia,8 and about 2% singing, or playing a musical instrument, and suffer from severe discrete performance anxiety.9 with nonartistic performances such as public Performance anxiety does not completely speaking, oral examinations, competing in sport- overlap with social phobia, however. Test-taking ing events, sexual activity, using public restrooms, anxiety and writer’s block, which can occur in a or being watched while doing a task such as nonpublic context, do not fit neatly into the social surgery, eating, or writing.2 phobia category.2 Thus, some performance anxi- Like social phobia, performance anxiety ety forms are better grouped as another type of probably develops in accomplished artists and anxiety disorder, such as specific phobia (Figure). not-so-famous individuals because of a mélange of genetic factors, innate temperament, parental DIFFERENTIAL DIAGNOSIS influences, conditioning events, and cognitive Social anxiety? Ask the patient about all situations influences.3 that provoke anxiety to differentiate between: 26 Current VOL. 4, NO. 6 / JUNE 2005 p SYCHIATRY Current p SYCHIATRY • discrete performance anxiety (1 or 2 perfor- Table 1 mance situations that provoke anxiety) 4 cognitive distortions • and generalized social anxiety (3 or more that underlie performance anxiety situations that provoke anxiety).9 Individuals with “trait” anxiety may exhibit • Overestimating threat innate shyness and are considered to have general- ized social phobia. Those with “state” anxiety • Underestimating own competence experience anxiety in specific situations or circum- • Selective attention to own arousal or to others’ stances and are more aptly described as having dis- negative responses crete performance anxiety.10 Whereas persons with • Negative, pessimistic self-talk social phobia may avoid the feared activity without inner conflict, those with performance anxiety are committed to performing the activity and are dis- Cognitive symptoms. Four cognitive distortions are tressed when unable to perform.9 common in persons with social phobia (Table 1).11 Specific phobia? A specific phobia is a circum- These negative thoughts are presumably the same scribed fear of a specific object, situation, or activi- for performance anxiety, at least when it is a sub- ty from which a grim outcome is feared. Specific type of social phobia. phobia usually has no performance aspect or fear Somatic symptoms. Persons with performance of embarrassment or failure. anxiety tend to have heightened awareness of Some clinicians consider certain perfor- hyperadrenergic arousal symptoms (Table 2, page mance anxieties—such as writer’s block, test- 28), sometimes in all body systems. Symptoms taking anxiety, paruresis, and even fear about may resemble those of a panic attack. sexual performance—to be specific phobias. Behavioral symptoms. Behavioral symptoms in- Because performance anxieties and phobias clude stuttering, mumbling, trembling voice, share some cognitive and behavioral compo- yawning, biting nails or lips, gritting jaw, poor nents, their treatments are similar and use of eye contact, shuffling or tapping feet, unnatural medication is controversial. or rigid postures or movements, warming up too General medical condition? Perform or refer the fast or too slowly, wearing excessive makeup, or patient for a thorough medical evaluation before smiling abnormally. A performer may forget to you diagnose performance anxiety, as endocrine, carry out a routine task such as blinking, moist- cardiovascular, respiratory, and circulatory abnor- ening lips, or turning a page of music. malities can mimic or exacerbate anxiety disorders. These behaviors may perpetuate and reinforce Also consider substance abuse or withdrawal as anxiety by eliciting negative reactions from an possible causes of anxiety. audience and fulfilling the performer’s pessimistic expectations. The therapist can identify these mal- PATIENT EVALUATION adaptive behaviors and target them for treatment. Family history. Individuals with social anxiety often report a family history of generalized social anxi- PSYCHIATRIC COMORBIDITY ety, panic disorder, or major depressive disorder.3 About one-third of individuals with performance Similar findings seem plausible for persons with anxiety have psychiatric comorbidities.9 Most discrete performance anxiety, although compara- common are other anxiety disorders, specifically ble family history data have not been reported. the generalized form of social phobia, generalized VOL. 4, NO. 6 / JUNE 2005 27 Stage fright Table 2 multimodal approach addressing behavior, affect, Somatic symptoms sensation, imagery, cognition, interpersonal rela- 9 of performance anxiety tionships, and biological factors. The performing arts community is competi- Bodily system Symptoms tive, and individuals may have differing standards about what treatments are acceptable. Some may Autonomic Blushing, diaphoresis, view using medications as “cheating” or an admis- dry mouth sion of professional failure. A performer may feel GI, urologic Urinary or bowel medication gives an unfair advantage, that respect urgency, GI discomfort would be lost if others found out, or that taking Cardiovascular Tachycardia, palpitations medication before performing is similar to steroid use by athletes.17,18 Neuromuscular Muscle tension, tremor, Medication vs. psychotherapy. Medication can help paralysis diminish anxiety’s physical symptoms, but cer- tain psychotherapies rely on these somatic symp- toms for effective treatment and extinguishing of anxiety disorder, panic disorder, or specific pho- responses. Concurrent use of medications and bia.12 Mood disorders are less common. We also psychotherapy for social phobia is common in recommend monitoring for eating disorders everyday practice, although some studies find the because some performing artists are driven to combination no more effective than either treat- maintain high physical appearance standards. ment alone.11 Symptoms appear less likely to Personality disorder comorbidities with perfor- return after cognitive-behavioral therapy (CBT) mance anxiety have not been studied. Some ends than after medication is discontinued.16 experts believe that avoidant personality and Discuss treatment options with the patient. A social phobia are the same conditions expressed patient who feels unable to perform without to varying degrees on a continuum.13 Other per- medication may develop psychological depen- sonality disorders to consider include schizoid, dency. Conversely, a patient may not be able to paranoid, and obsessive-compulsive personalities. afford the full course of psychotherapy needed for Alcohol and substance use disorders are highly positive results. For performing artists, longer vis- comorbid with performance anxiety. Alcohol use its that incorporate medication management with decreases public speaking anxiety,14 and approxi- psychotherapy