Ready, steady, perform: the use of beta-blockers in performance anxiety

Screen Shot 2015-09-03 at 7.46.42 PMIn medical school, we had exams called OSCEs, which were simulated doctor-patient interactions. Our “patients” were trained volunteers who graded us on how much like real doctors we could act like.

This would make anyone, especially neurotic medical students, nervous, but one of my friends had severe anxiety about these exams. Like, SEVERE.

While many of us crammed for these exams two hours beforehand, she spent the week leading up to the exam studying and practicing. Still, she had sweats and uncontrollable shaking during the exam and during one session, cried while getting feedback.

Her doctor prescribed her a beta-blocker called propanolol, a medication usually used for high blood pressure, but which is also used for performance anxiety because it “steadies the nerves.” She reported feeling much better afterwards, and I was glad that she got treatment, but I wondered: could using beta-blockers be considered performance enhancement and even cheating?


Beta-blockers have long been known to reduce anxiety and allow performers to “chill” before concerts, public speeches, and heart surgery. That’s why they’re considered a form of doping in competitive sports like riflery (shooters can fire between heartbeats, avoiding jolts), motorcycling, bobsledding, and snowboarding where a muscle twitch can make the difference between medaling and not.

It’s been a contentious issue in the world of professional musicians, where some protest it would be irresponsible to not use it, and others passing it off as a crutch for lesser musicians. “If you have to take a drug to do your job, then go get another job,” said Sara Sant’Ambrogio, who plays cello in the Eroica Trio.

What did I find in my brief review of the literature? Beta blockers work for performance anxiety. There are studies such as this small one showing that using propanolol actually improved music performance as judged by music critics. One interesting randomized, blinded study of ophthalmology residents found that propanolol reduced anxiety and improved tremor during surgery–but didn’t have a significant impact on surgical outcome.

On the other hand, there is also a concern that beta blockers may have too much of an effect on an important part of anxiety: memory.

This Nature report briefly outlines work that investigates how beta blockers might be used to treat PTSD because of its effects of memory formation in stressful situtations. However, others have pointed out that this aspect of beta blockers might become abused. For example, what if soldiers were given beta blockers to block out the stress of killing innocent bystanders, which could make it easier for them to continue doing so? There will always be ways to stretch a drug’s power beyond what it is ethically responsible to do, and we have to be careful about how easily we condone the use of drugs for new purposes.

But anyway–back to performance anxiety.

While I would be tempted to call medical students’ of beta blockers “cheating,” lord knows that there is a lot of crap we have to go through in medical training intended to weed people out. Organic chemistry? Getting honors in a certain number of classes? Suturing just the way an attending likes so you can ask for a rec letter later? Pretending to be a nice person when really you just want to pass an in-person exam and go home and put on pajamas?

If using a beta blocker is what it takes to make sure that really kind, dedicated individuals who sometimes get anxious make the cut, then so be it.


About the friendly intern

Ask a question: The Friendly Intern My personal blog: Pathos and Pathology
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