Somatic symptoms. Persons with performance anxiety tend to have heightened awareness of hyperadrenergic arousal symptoms (Table 2), sometimes in all body systems. Symptoms may resemble those of a panic attack.
Behavioral symptoms. Behavioral symptoms include stuttering, mumbling, trembling voice, yawning, biting nails or lips, gritting jaw, poor eye contact, shuffling or tapping feet, unnatural or rigid postures or movements, warming up too fast or too slowly, wearing excessive makeup, or smiling abnormally. A performer may forget to carry out a routine task such as blinking, moistening lips, or turning a page of music.
These behaviors may perpetuate and reinforce anxiety by eliciting negative reactions from an audience and fulfilling the performer’s pessimistic expectations. The therapist can identify these maladaptive behaviors and target them for treatment.
Table 1
4 cognitive distortions that underlie performance anxiety
|
Table 2
Somatic symptoms of performance anxiety
| Bodily system | Symptoms |
|---|---|
| Autonomic | Blushing, diaphoresis, dry mouth |
| GI, urologic | Urinary or bowel urgency, GI discomfort |
| Cardiovascular | Tachycardia, palpitations |
| Neuromuscular | Muscle tension, tremor, paralysis |
PSYCHIATRIC COMORBIDITY
About one-third of individuals with performance anxiety have psychiatric comorbidities.9 Most common are other anxiety disorders, specifically the generalized form of social phobia, generalized anxiety disorder, panic disorder, or specific phobia.12 Mood disorders are less common. We also recommend monitoring for eating disorders because some performing artists are driven to maintain high physical appearance standards.
Personality disorder comorbidities with performance anxiety have not been studied. Some experts believe that avoidant personality and social phobia are the same conditions expressed to varying degrees on a continuum.13 Other personality disorders to consider include schizoid, paranoid, and obsessive-compulsive personalities.
Alcohol and substance use disorders are highly comorbid with performance anxiety. Alcohol use decreases public speaking anxiety,14 and approximately 6% of orchestral musicians use alcohol before a performance.15 For comparison, approximately 16% of patients who present for treatment of generalized anxiety disorder abuse alcohol, often as an attempt to self-medicate.16
TREATMENT PLANNING
Just as performance anxiety’s diagnostic classification may vary, so may treatment. Pharmacologic interventions and psychotherapy for social and specific phobias are similar. Some clinicians favor a multimodal approach addressing behavior, affect, sensation, imagery, cognition, interpersonal relationships, and biological factors.9
The performing arts community is competitive, and individuals may have differing standards about what treatments are acceptable. Some may view using medications as “cheating” or an admission of professional failure. A performer may feel medication gives an unfair advantage, that respect would be lost if others found out, or that taking medication before performing is similar to steroid use by athletes.17,18
Medication vs. psychotherapy. Medication can help diminish anxiety’s physical symptoms, but certain psychotherapies rely on these somatic symptoms for effective treatment and extinguishing of responses. Concurrent use of medications and psychotherapy for social phobia is common in everyday practice, although some studies find the combination no more effective than either treatment alone.11 Symptoms appear less likely to return after cognitive-behavioral therapy (CBT) ends than after medication is discontinued.16
Discuss treatment options with the patient. A patient who feels unable to perform without medication may develop psychological dependency. Conversely, a patient may not be able to afford the full course of psychotherapy needed for positive results. For performing artists, longer visits that incorporate medication management with psychotherapy may be more successful than brief, symptom-targeted visits.
MEDICATION MANAGEMENT
All medication use for performance anxiety is off-label. The most common choices are short-acting agents such as beta blockers or benzodiazepines (Table 3).
Table 3
Medications used to treat performance anxiety*
| Medication | Typical dosage | Possible side effects |
|---|---|---|
| Beta blockers | Medical: sedation, fatigue, dizziness, ataxia, nausea, sexual dysfunction Psychiatric:insomnia, nightmares, depression Contraindications: heart failure, bradycardia, breathing difficulties, hypotension | |
| Propranolol | 10 to 40 mg | |
| Nadolol | 20 to 120 mg | |
| Atenolol | 50 to 100 mg | |
| Benzodiazepines | Performance decrement, amnesia, sedation, discontinuation symptoms, tolerance, abuse potential | |
| Clonazepam | 0.25 to 0.5 mg | |
| Lorazepam | 0.5 to 1 mg | |
| * Off-label use; taken as-needed approximately 1 hour before performance | ||
Beta blockers can relieve autonomic and somatic symptoms such as tachycardia, tremor, and stuttering when used in low doses as needed for mild to moderate circumscribed performance anxiety.16,19 Propranolol, 10 mg about 1 hour before the performance, is most often prescribed.
Before prescribing a beta blocker, evaluate the patient’s medical history and cardiovascular status, including blood pressure and pulse. Have the patient try a test dose before the first live performance to check for side effects and tolerability (Table 3).16,19
Benzodiazepines have been used to treat social anxiety, but controlled studies have not reliably addressed their efficacy in performance anxiety. Advise the patient to abstain from alcohol when taking these medications (Table 3).
PSYCHOTHERAPY OPTIONS
CBT with components of exposure and retraining can ameliorate performance anxiety.10,20