952
EFFECT OF OXPRENOLOL ON STAGE-FRIGHT IN MUSICIANS I. M. JAMES D. N. W. GRIFFITH
R. M. PEARSON PATRICIA NEWBURY
of Clinical Pharmacology, Academic Department of Medicine, Royal Free Hospital, London NW3 2QG
Section
The effect of 40 mg oxprenolol on stagefright was assessed in 24 musicians in a double-blind crossover trial. Musical performance judged by two professional assessors was found to improve. Greatest improvement was seen on the first performance and in those most affected by nervousness.
Summary
Introduction ALTHOUGH enhanced sympathetic activity increases response in the classical fight-or-flight situation, excessive sympathetic drive can impair performance, particularly in complex manipulations carried out under stress. Skill, coordination, and judgement may all be adversely affected. Excessive catecholamine release causes tachycardia and muscle tremor and may further increase anxiety. Infusion of catecholamines or their release from a pheeochromocytoma can cause anxiety. There seems to be a positive feedback of anxiety causing catecholamine release, which causes further anxiety. Traditionally, centrally acting anxiolytic drugs have been used to break this vicious circle, but these nearly always cause undesirable side-effects, such as sedation,2 which may lead to deterioration in the performance of skilled tasks. The aim is control of anxiety without central-nervous-system side-effects. The use of beta-adrenoceptor-blocking drugs to treat anxiety was suggested by Granville-Grossman and Turner,3 and Tyrer and Lader4 confirmed their usefulness in anxious patients with predominantly somatic symptoms. Turner and Hedgess showed that the betaadrenoceptor-blocking drug, oxprenolol, given orally in a dose of 40 mg or 80 mg to normal volunteers, did not affect central-nervous-system function. In the study described here we measured the effect of oxprenolol on stage-fright-the natural anxiety and stress of performing in public-in musicians. Professional musicians recognise that excessive anxiety can impair performance, sometimes with catastrophic results. On the other hand, some degree of apprehension is often said to be essential for a good musical performance. We investigated stage-fright in string players, since tremor (an adverse effect) is easily seen in them. Methods
Study Design The study was a conventional two-way crossover doubleblind clinical trial. The subjects’ performance and physiological variables were assessed on two separate days, once after oxprenolol (40 mg) and once after matching placebo. Sufficient anxiety was engendered in the subjects, on the advice of the musical advisers, Peter Turton and Harald Strub, of the London College of Music, by mounting the study before an invited audience in the Wigmore Hall, where a solo debut is regarded as a "testing experience". Performances were recorded with a battery of "very obvious" microphones, and access to the hall by press, radio, and television was regulated to make both days equally stressful.
Subjects 24 healthy volunteers (6 men and 18 women aged 18-47 [mean 23]), mostly from the London colleges and academies of music, were studied. All were string players intent on making music
They
and were not selected for undue nervousness. free from asthma and nervous or mental illness.
a career were
Ethical Considerations The participants were examined clinically, and consent was obtained from them, their own physicians, and the hospital ethics committee.
Drugs The subjects attended at the Wigmore Hall at 12.30 P.M. on separate days. No drugs, coffee, or alcohol were allowed on the day of the study. On the first day 12 doses of oxprenolol (40 mg) and 12 of placebo were allocated at random to the 24 volunteers, who took them 90 min before their individual performances. On the second day the subjects who had had oxprenolol on the first day received placebo and vice versa. two
Assessments Clinical Assessment
before Performance
The subjects were assessed immediately before and after their performances by the same two clinicians throughout the study. The presence and degree of nervousness was assessed in two ways. Each musician selected the word which most nearly described his or her feelings from the following graded list: (1)
nonchalant; (2) calm; (3) uneasy; (4) tense; (5) terrified; or (6) panicky. On a visual analogue rating scale (V.A.R.S.) the subject also marked, on a 100 mm horizontal line, the point which he felt represented his feelings. The two extremes were "I feel relaxed" (0 mm) and "I feel petrified" (100 mm). Pulse and blood-pressure were measured after the subject had stood for 3 min. These physiological measurements were carried out after assessment of nervousness and were not disclosed to the
performer or assessors. MusicalAssessment The performance was scored by two professional musicians experienced in adjudicating competitions. They were "blind" not only to the drug therapy but also to the medical assessments and to each other’s scoring. Each performer played two set pieces, one from the music and one from memory. These pieces were scored separately and were marked from 0 to 10 with respect to each of the following musically important points: accurate shifting, vibrato, intonation, and musicianship (left hand); bowing, lack of tremor, and musicianship (right hand). The maximum possible score for each piece was therefore 70. Memory was separately scored 0-10. Assessment after
Performance Immediately after performing, subjects chose a word to describe the performance from the following graded list: (1) terrible ; (2) bad; (3) fair; (4) good; or (5) very good. They also used a V.A.R.S. to describe their emotional state, as indicated by the expressions "I feel euphoric" (0 mm) on the one hand and "I feel hopeless" (100 mm) on the other.
Results ClinicalAssessment before There
was
no
Performance significant difference
in heart-rate,
blood-pressure, or nervousness between the first and second performances for the combined drug and placebo scores. Oxprenolol caused a significant fall in pulse-rate from 99 to 75 per min and a slight fall in systolic bloodpressure from 125 to 110 mm Hg. Nervousness was sig-
953 TABLE I-SELF-ASSESSMENT
TABLE II—MEAN VALUES FOR ANALYSIS OF VARIANCE OF TOTAL SCORES OF MUSICAL ASSESSORS’ RECORD
occasions. There was, however, a significant ment in both of these variables on oxprenolol.
improve-
Discussion
TABLE III -MEAN SCORES FOR THE MUSICAL
ASSESSORS’
RECORD
OF INDIVIDUAL ASPECTS OF MUSICIANSHIP
a s.=not
The main finding was that oxprenolol caused a significant improvement in overall muscial performance. Subjects with lower total scores on placebo seemed to improve most when on the drug. Although overall mean improvement was only about 5%, in some subjects there was a 30% improvement. One individual showed a 73% improvement in total score. The fact that oxprenolol had more effect when given on the first day is to be expected. The difference between drug and placebo scores is less on the second day because of an improvement in the mean placebo score. The mean of the players’ self-assessment of performance indicated no significant change between first and second sessions. 15 players made a correct self-assessment of change in their performance. 3 players assessed themselves as bet-
significant.
nificantly decreased on oxprenolol whether visual analogue or graded scale (table I). Musical Assessment Variance was analysed
on
rated
by
the musical assessors’ total
(table n). Oxprenolol produced a highly signifiimprovement in the total scores (P
EFFECT OF OXPRENOLOL ON STAGE-FRIGHT IN MUSICIANS I. M. JAMES D. N. W. GRIFFITH
R. M. PEARSON PATRICIA NEWBURY
of Clinical Pharmacology, Academic Department of Medicine, Royal Free Hospital, London NW3 2QG
Section
The effect of 40 mg oxprenolol on stagefright was assessed in 24 musicians in a double-blind crossover trial. Musical performance judged by two professional assessors was found to improve. Greatest improvement was seen on the first performance and in those most affected by nervousness.
Summary
Introduction ALTHOUGH enhanced sympathetic activity increases response in the classical fight-or-flight situation, excessive sympathetic drive can impair performance, particularly in complex manipulations carried out under stress. Skill, coordination, and judgement may all be adversely affected. Excessive catecholamine release causes tachycardia and muscle tremor and may further increase anxiety. Infusion of catecholamines or their release from a pheeochromocytoma can cause anxiety. There seems to be a positive feedback of anxiety causing catecholamine release, which causes further anxiety. Traditionally, centrally acting anxiolytic drugs have been used to break this vicious circle, but these nearly always cause undesirable side-effects, such as sedation,2 which may lead to deterioration in the performance of skilled tasks. The aim is control of anxiety without central-nervous-system side-effects. The use of beta-adrenoceptor-blocking drugs to treat anxiety was suggested by Granville-Grossman and Turner,3 and Tyrer and Lader4 confirmed their usefulness in anxious patients with predominantly somatic symptoms. Turner and Hedgess showed that the betaadrenoceptor-blocking drug, oxprenolol, given orally in a dose of 40 mg or 80 mg to normal volunteers, did not affect central-nervous-system function. In the study described here we measured the effect of oxprenolol on stage-fright-the natural anxiety and stress of performing in public-in musicians. Professional musicians recognise that excessive anxiety can impair performance, sometimes with catastrophic results. On the other hand, some degree of apprehension is often said to be essential for a good musical performance. We investigated stage-fright in string players, since tremor (an adverse effect) is easily seen in them. Methods
Study Design The study was a conventional two-way crossover doubleblind clinical trial. The subjects’ performance and physiological variables were assessed on two separate days, once after oxprenolol (40 mg) and once after matching placebo. Sufficient anxiety was engendered in the subjects, on the advice of the musical advisers, Peter Turton and Harald Strub, of the London College of Music, by mounting the study before an invited audience in the Wigmore Hall, where a solo debut is regarded as a "testing experience". Performances were recorded with a battery of "very obvious" microphones, and access to the hall by press, radio, and television was regulated to make both days equally stressful.
Subjects 24 healthy volunteers (6 men and 18 women aged 18-47 [mean 23]), mostly from the London colleges and academies of music, were studied. All were string players intent on making music
They
and were not selected for undue nervousness. free from asthma and nervous or mental illness.
a career were
Ethical Considerations The participants were examined clinically, and consent was obtained from them, their own physicians, and the hospital ethics committee.
Drugs The subjects attended at the Wigmore Hall at 12.30 P.M. on separate days. No drugs, coffee, or alcohol were allowed on the day of the study. On the first day 12 doses of oxprenolol (40 mg) and 12 of placebo were allocated at random to the 24 volunteers, who took them 90 min before their individual performances. On the second day the subjects who had had oxprenolol on the first day received placebo and vice versa. two
Assessments Clinical Assessment
before Performance
The subjects were assessed immediately before and after their performances by the same two clinicians throughout the study. The presence and degree of nervousness was assessed in two ways. Each musician selected the word which most nearly described his or her feelings from the following graded list: (1)
nonchalant; (2) calm; (3) uneasy; (4) tense; (5) terrified; or (6) panicky. On a visual analogue rating scale (V.A.R.S.) the subject also marked, on a 100 mm horizontal line, the point which he felt represented his feelings. The two extremes were "I feel relaxed" (0 mm) and "I feel petrified" (100 mm). Pulse and blood-pressure were measured after the subject had stood for 3 min. These physiological measurements were carried out after assessment of nervousness and were not disclosed to the
performer or assessors. MusicalAssessment The performance was scored by two professional musicians experienced in adjudicating competitions. They were "blind" not only to the drug therapy but also to the medical assessments and to each other’s scoring. Each performer played two set pieces, one from the music and one from memory. These pieces were scored separately and were marked from 0 to 10 with respect to each of the following musically important points: accurate shifting, vibrato, intonation, and musicianship (left hand); bowing, lack of tremor, and musicianship (right hand). The maximum possible score for each piece was therefore 70. Memory was separately scored 0-10. Assessment after
Performance Immediately after performing, subjects chose a word to describe the performance from the following graded list: (1) terrible ; (2) bad; (3) fair; (4) good; or (5) very good. They also used a V.A.R.S. to describe their emotional state, as indicated by the expressions "I feel euphoric" (0 mm) on the one hand and "I feel hopeless" (100 mm) on the other.
Results ClinicalAssessment before There
was
no
Performance significant difference
in heart-rate,
blood-pressure, or nervousness between the first and second performances for the combined drug and placebo scores. Oxprenolol caused a significant fall in pulse-rate from 99 to 75 per min and a slight fall in systolic bloodpressure from 125 to 110 mm Hg. Nervousness was sig-
953 TABLE I-SELF-ASSESSMENT
TABLE II—MEAN VALUES FOR ANALYSIS OF VARIANCE OF TOTAL SCORES OF MUSICAL ASSESSORS’ RECORD
occasions. There was, however, a significant ment in both of these variables on oxprenolol.
improve-
Discussion
TABLE III -MEAN SCORES FOR THE MUSICAL
ASSESSORS’
RECORD
OF INDIVIDUAL ASPECTS OF MUSICIANSHIP
a s.=not
The main finding was that oxprenolol caused a significant improvement in overall muscial performance. Subjects with lower total scores on placebo seemed to improve most when on the drug. Although overall mean improvement was only about 5%, in some subjects there was a 30% improvement. One individual showed a 73% improvement in total score. The fact that oxprenolol had more effect when given on the first day is to be expected. The difference between drug and placebo scores is less on the second day because of an improvement in the mean placebo score. The mean of the players’ self-assessment of performance indicated no significant change between first and second sessions. 15 players made a correct self-assessment of change in their performance. 3 players assessed themselves as bet-
significant.
nificantly decreased on oxprenolol whether visual analogue or graded scale (table I). Musical Assessment Variance was analysed
on
rated
by
the musical assessors’ total
(table n). Oxprenolol produced a highly signifiimprovement in the total scores (P
