Hi,

I've just come back from a CPD day, and one of the subjects discussed was the use of drugs in mental health. Beta Blockers were mentioned as being particularly useful for musicians with pre-performance nerves.

I just wondered whether any singers have used them, and what were the effects. I love the idea of finding a way of managing my nerves, but am worried that the drugs could detract from the performance.



Ambs
x

.

I agree with Mezzo - I have never come across any singers who have taken them, and would advise against any drugs to help nerves. The strongest thing I take is passion flower and chamomile, which just takes the edge off (you still feel nervous) but still leaves you in full control of your concentration.

I'd suggest talking to a doctor about it rather than to musicians with no medical training.
Beta blockers have their place in the management of anxiety; they are not for everyone and hence are prescription-only medicines, but I'd treat non-medical advice on medical issues with some scepticism. I've seen a lot of harm done to people from misguided advice from their acquaintances against taking medication they need - and comments such as the above could well end up putting off people who need this or other medicines for other conditions.

*signed*
a musical medic. MBChB MRCGP. Oh, and ATCL.

Wot anacrusis said...but at the same time, I can't help noticing that beta blockers have become "OK" for musicians, yet other groups of people who suffer from performance anxiety, and whose anxiety can have significant effects on their performance, still don't seem to have this feeling that it needs to be medicated as a matter of course. Just an observation.

Yes, I agree. The only "cure" for performance nerves is do it, do it, do it. But regularly, and therein lies the problem - not everyone gets the opportunity to perform as regularly as that.

Nervous singers should sing everywhere at every opportunity, be it in church, in the car, at family gatherings or just around the house. Get used to letting your voice out in front of others where ever that might be. I sang a Mozart aria in Tesco's in Bangor once for a dare. A nervous friend didn't believe that I would. (She really should have known me better!) Take part in as many concerts as possible. Singing in a choir helps. Do festivals, take part in Forum events, anything but just get out there and sing! The nerves will pass eventually. The only thing that I do to overcome nerves is a visualisation technique where I imagine myself on stage giving a great and perfect performance. If you do this several times before a performance your brain will be fooled into thinking that the perfect performance will happen, having been in that situation many times before.
I am sure that medication has a place but onjy as a last resort and then only to help to break the cycle of being too nervous to perform.

You are of course right. But this is not a question of telling someone not to comply with their doctor's advice AFTER they've been prescribed necessary medication (I certainly wouldn't have a pulserate under 120 without them at the moment).
What I tried to say was that betablockers are not some herbal or Bach's rescue remedy you just try to see how it works.

The problem about betablockers is that they have become "chic" for people who could well cope with their nerves without them. We don't have to take pills for every bit of stagefright, it's a natural response of our body we should be able to cope with, and it gets better with practice. Not every little shake, a pulserate over 100 or sweaty palms need betablockers, and I find it actually quite worrying that so many perfomers these days take betablockers for every little bit of nerves kicking in, and that's sadly a fact. When I was still working at the theatre, I would say roundabout half of the people there took them, most of them perfectly healthy - betablockers were just the easy way to cope with performance nerves, and that is imho wrong. It is of course easier to just swallow a pill than accepting that stagefright is a natural physical response to stress that can be dealt with in other ways (only that it takes more time and effort).

If someone has a REAL anxiety problem, that's a different matter and should be discussed with their GP or even a psychotherapist ...

A note then to those who do take betablockers for performance anxiety - and by the way, they are not just prescribed to musicians, they are used just as often in other settings, only musicians happen to talk about it - if they work for you, don't let the somewhat belittling tone of some of the above posts put you off. It is not a matter of pride to manage without, everyone is different, and it would be a shame for someone to find their otherwise wonderful musicality crippled because of such an anxiety when there is the possibility of help. I'm not talking here about a bit of feeling wound up before performing, I'm talking about the sort of anxiety which stops the performance from ever getting off the ground, when in rehearsal it would work no problem.

And on the natural remedies front, can I just remind everyone that some of nature's most powerful poisons are derived from plants? It bewilders me that people can pour all sorts of stuff into their bodies just because it's "natural" but still baulk at use of rather more reliably researched and accurately dosed medication. I'm no pill-pusher, am both cautious in prescribing and in taking medication myself, but where it's needed, I will do so.

anacrusis, I don't know what is "belittling" about warning of the use of a quite strong medication just "to give it a shot" (btw.: I don't take herbal remedies )?
I don't know Amber - if she has a real anxiety problem then she might well need them, and I am certainly not against medication where it has its place. But that's up to the GP to decide, and it's certainly not down to the fact whether other people in these forums or somewhere else have made good or bad experience with them. It is down to the individual and should be discussed with their doctor.

I am certainly thankful that they exist for different reasons. If someone is absolutely crippled by their nerves and cannot even hit the right key because their hands are shaking so badly, that's a different case, and I would never say that a person like that might not need them. But what I absolutely oppose to is the sadly very relaxed use of betablockers under professional performers, and that is a fact, you just have to look round ...

OK, put yourself in the shoes of the very anxious person wondering about consulting their doc for this one. They will likely feel inadequate for being anxious, anxious about going to consult for feeling anxious, anxious about admitting that they feel this way. This is something our culture easily dismisses as "merely being a bit worried", and it's a vicious cycle- those who don't feel that way don't understand it or identify with it, those who have it don't feel they dare admit to how bad it is because others talk in terms of "snapping out of it" or using willpower to deal with it. Certainly, repeated exposure to the thing which worries us can help, but it also can serve to make things worse if things go wrong. Someone who is looking for reassurance in this thread finds only comments that people use medication too easily, that other solutions are better, and assumes that this applies to them also, and that if they do resort to medication, they are somehow the less for it. We don't ever see the full impact of anxiety on the sufferer, because they are already trying to suppress it as much as possible - so remarks such as have been made serve only to dismiss the impact of their symptoms, and to make them feel worse. I happen to know this because I am a doctor and see a lot of anxiety - once in the safety of an accepting and private environment, the full story, not told outwith the surgery, comes out.
I in no way condone the casual handing out of medication, from one person to another for whom it has not been prescribed; what I am keen to avoid is that people seeking reassurance and help should be made to feel inadequate or more afraid to do so by opinion which is not backed by training.

edited, retrospectively too personal

Hmmm..erased what I could have said about use of beta-blockers in Japan...

I understand what anacrusis is saying, but feel that in her entirely understandable effort to show that beta blockers are sometimes justified and useful, she included an unjustified implication that herbs are dangerous, the people who produce them unscientific, and those who use them ignorant. As anacrusis says, anybody could read this thread and come to wrong conclusions. They might even think that all herbs are powerful poisons...

I know there are powerful herbs with the reputation for calming anxiety, but I would never mention them here, or even use them myself without qualified advice. Instead, there are so many mild plants which offer a little relief while I assess whether I need expert advice and treatment. Misuse of powerful prescribed or even OTC medication is surely no better (or worse) than misusing powerful herbs.

The modern pharmacoepia is not short of non-synthesized plant-sourced chemicals, as well as many that are synthetic copies of plant chemicals...and the justification for their use is sometimes more empirical than we would like to think.

A certain OTC cold remedy froma reputable pharmaceutical company is presumably well researched and dosage carefully calculated...but wait, it contains two plant-derived chemicals, one synthetic copy of a plant chemical whose use is based largely on empirical studies, and another whose safety and efficacy is debated every bit as hotly as any OTC herbal remedy ever was!

My comments on herbal remedies have a lot to do with the overpriced stuff peddled by "health food" stores with claims for miraculous cures for all sorts of ailments - they can be bought without needing any advice because they are not classed as medicines, yet some of them have interactions with prescription medicines. The common misperception is that herbs are somehow safer, and will only be beneficial, not detrimental, and this is by no means always the case. My original statement about poisons used the term "some", not "all", and I stick by that. I get frustrated by the alternative lobby telling my patients that I'm not interested in the whole person*, that the medicine I underwent eight years' training to be able to practise is purely interested in shoving a pill at every ill, and I get angry that my patients, many of whom are on tiny budgets, are misled into spending lots of money on concoctions for conditions which get better on their own. I have every respect for properly trained herbalists - they do have expertise and a broad knowledge-base, but how many people taking herbal remedies go and see one? There is also no regulation of dosages on the over-the-counter herbal remedies as far as I'm aware, and availability of active ingredients in plants varies with the weather, which does indeed make it a bit of a lottery as to how much is being taken.

Mezzo - I appreciate what you say about your experiences, but would still say this - it is an individual account, and we still cannot generalise from it sufficiently to justify the sort of advice which came up in this thread - you were careful enough to say that there were issues around taking medication, and still did say they have their place, but there were other statements simply advising against beta-blockers, full stop, and to that I take exception, not to your contribution.

Now, as I find the singers' bit a particularly scary place to be, I'll bow out at this point, rant over .

*as a GP, I'm well-placed to get to know the whole person, family relationships, friendship networks, even how they decorate their house and what they feed the cat , over a long period of time.

Given your own experiences with anxiety, I am somewhat confused at the stance you have taken in this thread. To begin with, you dispense advice that pills are likely unnecessary:



But, for a given reader of this thread, how do you know? As you say, you 'know the feeling of inadequacy and shame when you first have to admit you cannot cope' - that may be the case, but you are still setting things up here to make it more difficult for people to admit that, because that Mezzo1974 person on the Internet said they probably didn't need them and they should be able to cope with it. Then you turn on a sixpence in a manner that would impress a politician - a few posts down you add that:



... which, in effect, contradicts yourself. It appears, from the trail of posts in this thread, that you were comfortable dispensing your strong opinions on beta blockers until it was clear that doing so was ill advised, and then suddenly came out with the aforequoted post.


Throughout your posts, a common theme is that you are claiming there is some distinction between what you personally consider to be a mental health problem, and what you consider isn't worth going to see a medic about. I'm sorry, but having had mental health problems does not automatically mean you know what you are talking about, nor does it give you the clairvoyance necessary to make this distinction online - a fact you recognise but try to do anyway. It means you know about your experiences, and your perspective on things; to generalise beyond this is unwise and potentially dangerous.


Ultimately, if something has effects, it has side effects. Ignorance is the belief that plant-derived compounds are somehow able to evade that; mild or not, anything bar a placebo has the potential to cause harm. Hence, it is wise to seek medical advice on the issue. If you refer to anacrusis's very first post in this thread, I think you will find her recommendation that 'I'd suggest talking to a doctor about it rather than to musicians with no medical training.' This is sound advice, and I suggest anyone reading this thread follows that direction if they have any worries about performance anxiety.

Thank you ever so much for all your replies. There's lots of advice and interesting things for me to reflect on.

I guess, for me, the way that Beta Blockers were portrayed yesterday made them sound like some kind of magic wand solution to my nerves. Seemed almost too good to be true, which is why I wanted to check out with other musicians and hence my thread.

What particularly resonated for me was the notion that they treat the symptoms but not the cause. I'm smiling to myself as I write this because, as a qualified counsellor and psychotherapist, I spend my life encouraging clients to explore and resolve the causes of their distress. And yet here am I, seduced by the notion of a Magic Pill!

So I have decided to follow my own advice(!) and I've recognised that, with this particular concert which is looming, there are huge parallels with events that happened in my childhood. And that I don't need a pill, I just need to find and cathect the "adult" part of me, rather than the terrified "child". Being up on stage in front of an audience is no place for a terrified child!

I have low blood pressure also, and it sounds as though using beta blockers could possibly tip the balance from "manageable" to problematic, i.e. fainting on stage (eek, doesn't bear thinking about). So that's another reason for me to work on the root of the problem, rather than try to mask it.

My GP has been great and very supportive of me in terms of understanding and taking seriously my autoimmune disorder problems, so I would feel okay about talking to her about my performance anxiety. I don't know whether she would be quick to prescribe beta blockers or not. She's a great GP though.

Thank you again for all your responses, and I'm sorry that my thread provoked a bit of a disagreement.

Ambs x

YAP, wait a minute ...

It would help if you did not quote in such a selective manner, because I nowhere said pills are not necessary. What I said was that they are by no means always necessary. In the end, all our views are personal, and I think I made that clear more than once. I can of course add a "personal view" after every sentence if it makes you happier

In case betablockers are really needed (and that's by far not only against anxiety), they are good and helpful. I am also NOT opposed to betablockers in general - how ridiculous would that be? I have to take them myself, and I know that I would probably develop a heart weakness without them given the fact that I am constantly running full throttle pulsewise . I still would be happy to live without them. But please don't turn the words in my mouth ...

What I am opposing to is that people think they could be an easy way to deal with pre-performance nerves, which they are not. They are serious medication, full stop. Again, Amber asked about our pov/experiences, didn't she? And it is a difference if you are nervous before a performance or suffer from real anxiety, and yes, I happen to know the difference. *attention: personal experience, do not mistake to be generally valid*

I also said nowhere that I consider certain problems not being worth seeing your GP about - in fact, I said the extreme opposite and even mentioned in my very first post that if Amber suffers from extreme anxiety, she should discuss this with her GP. I am not so far away from what anacrusis said (I even said she was right more than once), and I fully appreciate her professional views on this matter. But it is worth mentioning that betablockers are not the easy solution since they only reduce symptoms. Again, you are quoting out of context here ...

It is potentially dangerous to talk people into taking medication they don't need as well as it is potentially dangerous to say "Don't take what your doctor prescribed". I did neither of those. But I have a strong opinion about it, yes ...

If you had used the quote facility yourself, and made it clearer which points you were responding too, it would help discussion greatly. As it happens, your posts consist of several paragraphs of dense text, and my piece-by-piece quoting was necessary to try and piece together something cohesive to which I could respond.



This is a theme you keep coming back to. (I've left a big quote so you can't argue the wheat I'm picking from the chaff is somehow out of context.) Essentially:

(i) you have experienced both depression-related anxiety and performance-related anxiety;
(ii) the former is worse - we are to 'trust you' on that one.

That is all well and good, and indeed does correlate with observable clinical reality. If it stopped there, it would be an interesting diversion; however, you then make some remarks about beta blockers being taken unnecessarily, implying that there are greater anxiety conditions which are more worthy. However, just because performance anxiety is often not as crippling as depression related anxiety, it doesn't mean it doesn't need help. There are various degrees of asthma, but no-one claims that only crippling cases warrant medical assistance. Ultimately, yes, you have had a bad experience with depression-related anxiety, and that sucks; however, it does not mean that normal performance anxiety is irrelevant.


Why only extreme anxiety, though? If it is enough to make someone's performing difficult, it would be worth seeing their GP. They might not get beta blockers, but they will get reassurance and advice - talked through some breathing and muscle-relaxation exercises, pointed towards books, and so on.

YAP, in the end everyone can read for themselves what I've written and what your interpretation of my words is or what I am supposed to have written in your opinion.

Just to clarify a couple of things for you:



To say it quite frankly: That is your interpretation of what I supposedly said. In fact, I said I experienced stagefright (that's a difference for me as you might notice if you take the time to read my posts) and depression-related anxiety which affected several parts of my life and also my life as a performer. I was anxious when I had to go on stage because of that. And yes, that WAS worse. While I could always get to grips with pre-performance nerves/stagefright, I couldn't get to deal with anxiety/panic attacks myself. Pre-performance nerves made me fell sick, caused palpitations and made me sweat, but that usually cleared after a while on stage (bad enough it made me hit bummers at the start ). Anxiety didn't, and I was sometimes not even able to perform in the first place. That is MY experience, and everyone has to find out for themselves, preferably with their doctors, what is THEIR problem.



I think you don't want to understand what I was writing, but once again: I never said that real performance anxiety is irrelevant. What I refuse to give an absolution to (and I won't get tired of it) is that someone takes betablockers for pre-performance nerves you can handle in a different way. You want to turn this in a judgemental comment I never made. I never made the judgement of something being better or worse that you are trying to stamp on my posts. But again: The original question of this post was if betablockers are really helping with pre-performance nerves. And I still say: No (at least not alone and certainly not in mild cases), because they are

a) not to be taken lightly and can have side-effects that can be worse than the symptoms you had
b) only make the symptoms go away, but not the cause.

If you suffer from anxiety, they might help you to function, but you will still have to work on the cause - which you effectively don't if you just take pills. It has to go hand in hand. It can be a first step, but the solution lies somewhere else.



Yes, and that's exactly the way to deal with "normal" pre-performance nerves. But it is so much easier to take pills, just have a look around in theatres and orchestras. There are certainly people there who need help, but I am just refusing to believe that literally half of working musicians are mentally ill and suffer from severe clinical anxiety. Fact is that betablockers get passed about like lozenges and are actually quite "hip" to calm down a bit before your concert. Sorry ...

But that's the last I will have said about this. Talk to your doctors if you have the feeling you cannot cope - there definitely is help out there, but it usually requires hard work on both sides ...

Thankyou, ambiguity is one of your strong points.


Taxonomic differences. I'll try again:

(i) you have experienced both depression-related anxiety that have affected your ability to perform; and pre-performance nerves/stagefright that have affected your ability to perform
etc. etc.

And, again, the former is worse; but it doesn't mean the latter cannot have a significant impact on the quality of life of someone, and that beta-blockers can be an appropriate solution. You are doing precisely what one ethically should not - you are allowing your own personal experiences with anxiety to directly influence your doctrine on what and what isn't an appropriate way to tackle problems.


So everyone has to find out for themselves; but if there's a chance they could handle the problem in another way they shouldn't take beta-blockers. Isn't planting that viewpoint interfering in them discovering a solution that works for them by suggesting that their occasional beta-blocker usage is somehow inappropriate, whereas it could be a quite appropriate tool to enable them to perform? My stance is that people should talk to their GP about it, and if they take beta-blockers, they take beta-blockers. It's none of my business, and I'm not going to go posting on the Internet about whether they are right or wrong - who am I to judge?


Incidentally, why? I mean, that's a good ethos in the general case, but what if one only gets the opportunity to perform in public for 2 minutes once a year? Is it always, irrefutably worth spending hundreds of pounds on therapy and going through the emotional upheaval for something which is an affliction for very few minutes across ones life, even if it the process was guaranteed to work?

YAP, anacrusis had brought this discussion to a quite good point and really put it in a nutshell with this:

before you stirred it up and tried provoke me with a couple of remarks that were actually not necessary - I am neither ambiguous, nor do I turn on a sixpence. But of course you are not judgemental yourself and do not only pick out what fits into your views, I've noticed that

Let's just agree to disagree ...

I am not a singer but have a lot of experience of beta-blockers; I have in past years found taking two 40mg. Propranolol tablets sufficient to take the edge off my nerves.
However, due to no specific cause that I can identify, my general state of anxiety has worsened and activities like accompanying pupils in their exams has become a source of greater nervous tension than I have ever experienced in previous years. (accompanying has always been something which I have enormously enjoyed and I can't understand why I am becoming so nervous about it.)
Basically I am now finding propranolol not strong enough - even if I take double the prescribed daily dose, it might, but is not guaranteed to, 'do the trick'.
For recent exam accompanying (including my wife's ATCL Viola exam!) I managed to persuade my doctor to give me Diazepam for a few days - it 'did the trick' but, as I understand it , it is not for long-term use.(unfortunately!)
If I am feeling tense when I come home from work, I will easily polish off at least half a bottle of whisky to calm me down - this might be the source of the problem. I have a lovely job, lovely wife and home so cannot understand why my nerves are playing up so much. Any suggestions from medical professionals on the forum would be greatly appreciated. I'm sorry that this post has become very selfish, but I feel I need help and advice.
Thanks,
Robert

I am sorry to hear that Bobsie. Get a proper health check from your GP and see what he or she has to say. Then try some simple fresh air and exercise on a regular basis. It works wonders often. Make time for a walk each day. If you have a dog you can take him out. too. We don't walk nearly enough these days and it is amazing how many physical conditions and states of mind are improved by more exercise.

First, your post is far from selfish - I will never begrudge someone opening up about mental health problems. If anything, people don't talk about these things enough, so thankyou for bucking the trend. Second, it is okay to be having such problems despite a lovely job and wife. It is a shame that these do not offer immunity, but I can offer my reassurances that your problems do not suggest you are ungrateful or are blaming them. The best thing you have done for your wife in this regard is to recognise your difficulties and seek advice - it's a big step in the right direction. Even if you only take little steps at a time from here, I do hope you can continue in the right direction.

I think the fact that your general state of anxiety has increased, along with you finding you need Diazepam for accompanying, suggests you need to go and talk to your GP about this. A couple of quick questions:

1) During the past month have you often been bothered by feeling down, depressed, or hopeless?
2) During the past month have you often been bothered by little interest or pleasure in doing things?

Make sure they get the broad picture - life in general, how it affects your work, and so on. Mention the whisky too; you say this is the 'source of the problem', but perhaps it's a symptom? Either way, talk to them - they won't consider you to be selfish, their concern will be for your well-being and what they can do to help you with that. If it helps, talk here in the meantime - it's no substitute to seeing a professional in person, but if you feel you'd benefit from airing a few thoughts, do go ahead. I can't promise to be around much for the next few weeks - as of Saturday I will have a lovely wife of my own - but if it helps, keep writing .

As an aside....


Yes, you're right. It's a long story, but I took 7.5mg a day for a few months, and am now coming off it. It's taken me 5 weeks to get down to 2.5mg, and it's been an 'interesting' experience.

Before Mezzo and YAP plunge their swords into one another...

Ambs. From what I know of your health problems I would steer clear of Beta blockers for nerves.
Due to your Auto-immune condition if performance nerves are really spoiling your singing experience have a good chat to your GP about it. Anacrusis has described well the type of relationship a good GP has with their patient, and take their advice.

Their may be no magic bullet. The breathing techniques associated with Yoga are calming, are drug free and would not interfere with your medical condition. Again with your GP find out if something like Yoga or Pilates would benefit you, as some of the meditations can be particularly good at combating performance stress. (IMHO) and are drug or herb free.

JoD

Thankyou Petrat and YAP for your supportive comments; it's reassuring to know that one can come onto the forums and get things off one's chest.
I forced myself out on the bike tonight to try to use up some adrenalin - I really enjoyed it and feel better for it. I don't think my anxiety is depression related, although I have had a number of big changes in my life over the past few years - perhaps these are catching up on me now.
I also have a couple of self-hypnosis CDs which do help (except at times when I am feeling really under pressure). However, I will persevere with them and see how things go.
Thankyou once again,
Robert.

That's great Robert. Well done. You'll have to join the Get Cycling thread in the cafe now.

Thanks again, Petrat. I should join, but I'm worried they might tell me off for not wearing a helmet!

I wouldn't worry Bobsie. I used to wear a helmet cycling, and found that the traffic skimmed past me thinking I was invincinble. One day I forgot, and suddenly I had a safety gap!

However, back on topic, you are not the first person on these forums who have needed therapy for nerves and "personal problems" and neither will you be the last. The great thing is you have recognised you have a problem and are dealing with it. Well done you!

Thankyou, Jod! In terms of excercise to help reduce stress, my wife has given me the options of either cycling a few miles a day, doing extra housework, or practising scales! I'll go for cycling any day!
But seriously, I know from experience that nerves/anxiety have an extremely damaging effect on quality of life and one's confidence in dealing with certain situations.
It is encouraging to hear that there are a number of forum members who have 'been there' and got through it. I, personally, am very touched by the number of supportive messages I have received since posting on this particular thread and want to say I am most grateful for all the advice which has been given.

So would I! In terms of a cycle helmet, the debate on them does get rather heated...but hopefully not here! Helmets are not compulsary in the UK, so as an adult you can make your own decision based on the information out there - although there is a wealth of evidence for both sides of the argument...I certainly wouldn't criticise anyone who chose to wear or not wear a helmet, though I might get annoyed if they zealously wanted to 'convert' me to their side of the argument.

I hope the cycling helps with your stress. For me, just knowing I am doing something for myself has always helped with my anxiety, and this cycling malarkey is really good!

I agree, Maizie! As a youngster I used to cycle miles on a smallish bike with 3 gears. Now, many years later, I am starting to relive the enjoyment of cycling again and I'm starting to get used to all the extra gears we have nowadays. (But, is it my imagination, or are the saddles much less comfy than they were 20 years ago?! )

Get thee to the cycling thread in the cafe Bobsie.

I'm so sorry to hear about what's going on for you Bobsie, and I do wish you all the best. I'm feeling so apprehensive about my concerts on Saturday, but I feel like I can't say anything about it on this thread any more.

Ambs - good luck. Wow that audience with that superb voice of yours

Bobsie - I wish you all the best for the future.

Best wishes for your concerts on Saturday, Amber; try to enjoy them.
Also, thanks for that, Barry.