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Playing with propranolol.

When an anxiety-reducing drug with virtually no side effects is used to enhance performance, is that cheating? Is it drug abuse? Is it an admission of professional weakness?

During a series of three performances, a trumpet player in a professional orchestra consistently plays a difficult solo passage flawlessly each time. Her colleague in the trumpet section marvels at her ability to play so well, since he knows that he and other professional players are unlikely ever to play that particular passage with consistent perfection. His assessment of his colleague's luck and talent changes, however, when he learns she takes ten milligrams of the drug propranolol before each performance that requires her to play difficult solo passages.

Although many people will agree on what constitutes ethical and unethical use of certain types of drugs, some kinds of drug use do not fit easily into either category. The patient who demands an antibiotic for a viral head cold, the athlete who requests steroids to enhance his or her performance, or the child who receives growth hormone injections because of a perceived social advantage to being tall present instances of drug use that are difficult to evaluate from a moral perspective. Propranolol for performance anxiety represents another instance of ethical ambiguity in regard to drug use.

The reason for such ambiguity is that the ethical evaluation of drug use is shaped by cultural beliefs and values, many of which lie hidden in commonsensical, unquestioned assumptions we make about our world. These implicit meanings, when they surface, often are in the form of vague images and incompletely articulated ideas. Furthermore, cultural images may have competing and contradictory meanings that add to the ambiguity of a moral evaluation of drugs and their use.

Propranolol use by musicians is an interesting case study for several reasons. It is a drug that can enhance one's performance and may increase one's advantage in the competitive field of the performing arts. As such, its use gives rise to moral questions similar to those raised by the use of steroids by athletes, such as fairness, or harm to the individual.[1] In addition, ambiguity about the meaning of performance anxiety and propranolol use complicates the moral issues. Is performance anxiety a normal phenomenon, as most musicians believe? At what point does it become pathological? Does the fact that physicians prescribe propranolol to treat performance anxiety confer upon it the status of disease? Or does the fact that musicians often obtain this prescription drug from their friends and take it before any important performance constitute simply another form of drug abuse?

Propranolol and Performance


Performance anxiety, or stage fright, has been defined as "the experience of persisting, distressful apprehension about and/or actual impairment of, performance skills in a public context, to a degree unwarranted given the individual's musical aptitude, training, and level of preparation."[2] Propranolol is a prescription drug increasingly used by symphony and opera musicians to eliminate symptoms of performance anxiety. The drug was first introduced for the treatment of angina pectoris, and later used to treat cardiac arrhythmias and hypertension and to prevent sudden death after myocardial infarction. Propranolol use was later extended to treat migraine headaches and symptoms of anxiety associated with stress.[3]

When a person is under stress, the sympathetic nervous system produces adrenaline-like chemicals that attach to beta-adrenergic receptor sites of the body. These sites produce physiological responses in heart rate, skeletal muscles, blood vessels, and bronchioles of the lungs and, in essence, prepare the body for a "fight or flight" reaction. Propranolol and other beta-blocking drugs compete with the adrenaline-like chemicals for these sites on the cells and block their physiological effects.[4] These effects include rapid heart beat, muscle tremor, dry mouth, sweating, nausea, and the urge to urinate. The presence of some anxiety symptoms may cause a further increase in symptoms that interfere with performance. Because it eliminates these physical impediments to performing well, propranolol is considered performance-enhancing. It does not increase the ability of the musician, nor is it effective against psychological symptoms such as anticipatory fear or negative thinking. Propranolol has been shown to be effective only in the treatment of bodily anxiety symptoms activated by the sympathetic nervous system.[5]

Although misuse of propranolol by persons with certain medical conditions may be harmful, most experts would agree that ten to twenty milligrams of propranolol taken by a normal, healthy adult has virtually no side effects, and several benefits. The main advantage of propranolol is that it will dispel nervous symptoms without causing the change in mental alertness that is typical of alcohol and certain classes of tranquilizers - both of which were used by musicians to control stress before the advent of propranolol. Controlled trials have demonstrated the effectiveness of beta-blocking drugs in improving musical performance.[6] Surgeons, test-takers, and persons about to give presentations have also been reported to use beta-blocking drugs to treat performance anxiety.

A 1987 survey by the International Conference of Symphony and Opera Musicians (ICSOM) of more than 2,000 of its members found that musicians are most likely to use beta-blocking drugs before auditions, solo recitals, difficult orchestral performances, and concerto performances.[7] The current incidence of propranolol use by musicians is not known, but the ICSOM survey reported that 27 percent of respondents used a beta-blocking drug, primarily propranolol, for performance anxiety. Of these, 70 percent reported that they occasionally used beta blockers without a prescription.

A more recent study at the University of lowa School of Music surveyed graduate students, undergraduates, and faculty. Of 302 respondents, approximately 1 to 3 percent reported using prescription drugs before performance either frequently or occasionally, while over one-third said they felt the use of a prescription drug for performance anxiety would be justified.[8] While these studies may indicate a difference in use and attitudes between professional musicians and students, anecdotal information suggests the practice of using propranolol before performances, either with or without a prescription, is fairly common.

Some Meanings Underlying Drugs,

Their Use, and Abuse

What influences our perception of the rightness or wrongness of drug use? Historically, the relief of pain and suffering has almost always been a desired goal of medicine. Using drugs to relieve pain has almost always been morally acceptable, although to some extent this depends on the kind of pain. For example, the use of drugs to relieve the psychic pain of American soldiers fighting in Vietnam was not considered acceptable unless the drugs were prescribed by a physician for a diagnosed mental illness.

Likewise, the moral acceptability of using drugs to relieve pain depends to some extent on the kind of persons to whom the drug is to be administered. In the past, relief of pain in childbirth was considered to be contrary to the biblical teaching that "in sorrow she will bring forth children." It was not until Queen Victoria used her considerable political clout to insist on the use of newly discovered anesthetics for the birth of her own children that pain relief during childbirth became morally acceptable. Beliefs that women in "primitive" cultures do not feel pain in childbirth and that infants are not affected by the pain of surgical procedures have flourished in more recent times.

Within our present historical period we can examine our moral beliefs about drugs by identifying some images and meanings we associate with them and noting how these meanings are connected to broader cultural beliefs and concepts. For example, that the ability to control oneself and one's actions without assistance from others is valued in American society can be seen in metaphors we commonly use - "being in the driver's seat," among others. The negative value placed on certain drugs is related to their interference with a person's capacity to act autonomously.

The meaning of drug use is also related to society's belief that hard work is morally good. The work ethic, dichotomizing work and leisure, renders pleasure morally suspect. Illicit sexual activity and excessive use of drugs such as tobacco and alcohol are considered "forbidden pleasures," and taxes on these drugs are still called "sin taxes."

The idea that excess is morally suspect is also related to the work/pleasure dichotomy. To engage to excess in any activity - eating, drinking, sexual activity (even between married persons) - is considered unhealthy and morally questionable. One can speculate that historically, movements against alcohol consumption may have been fueled in part by the social fact that husbands who drank excessively were unable to support their wives and children or were abusive toward them. As being a good husband meant being a good provider, and as money spent on alcohol or tobacco was money that would not be spent on food or luxuries for the family, excessive use of these drugs could prevent the husband from carrying out his duty to his wife and children.

Other images add to the construction of the immoral connotations of |excess.' The seven deadly sins - pride, anger, greed, sloth, envy, gluttony, and lust - are all sins of excess, either of behavior or of disposition. Another notion, that of the body's humoral balance, was a medical concept prevalent in the era of prescientific medicine that attributed disease to an imbalance or excess of bodily humors. The meaning of |excess,' then, suggests qualities that are both immoral and unhealthy. Today it is common to adopt the language of drug addiction in speaking of excessive behavior; people are said to be addicted to sex, food, gambling, and so on. |Addiction' evokes images of both excess and loss of self-control.

The Meaning of Propranolol Use

In addition to the broader cultural meanings of drug use, individual or personal meanings of drug use exist. Why does musicians' use of propranolol cause a sense of moral uneasiness for some? In contrast to steroid use by athletes, the relative safety of propranolol in small doses precludes the possibility of physical harm and is not an issue for most musicians. Musicians believe that some anxiety will positively enhance performance - a performer who is too "laid back" will not have the necessary drive and may deliver a sloppy performance. Because of this belief it would not seem likely that musicians would exceed the minimal dosages it is assumed they are using, although more systematic research is needed here.

Informal discussions with musicians reveal a reluctance to discuss propranolol use, which is seen by some as a sign of personal and professional weakness and an inability to cope with the stresses of their chosen career. Others have no qualms about taking the drug and consider it a necessary means of dealing with professional stress in a very competitive field. Some musicians attribute a negative moral evaluation to propranolol use insofar as "drug use," evokes the image of "drug abuse": consider the musician who says, "If I have to depend on drugs to get through a performance, I'll give up playing." The perceived possibility of psychological dependence, where the musician believes she would be unable to perform without the drug, suggests excessive use and loss of autonomous control, thereby evoking the image of addiction.

Another reason for musicians' moral ambiguity about the use of propranolol stems from the perception of unfair advantage. Consider again the orchestra musician who is the colleague of the musician who played the passage flawlessly under the influence of propranolol. His first reaction might be anger and a sense that his colleague is using unfair or dishonest tactics - that she is, in fact, cheating. His second reaction might be to get in touch with his internist, or to ask one of his colleagues for a dose or two of propranolol to take at his next audition or solo performance. Thus, the coercive aspect of performance-enhancing drug use among musicians is parallel to that of steroid use among athletes. If one person is perceived to have an advantage in using a drug, others will be compelled to use it in an attempt to even the ante, to return to the state of equilibrium that existed before drug use.

In discussing steroid use among athletes, Norman Fost suggests that fairness and equality, important values in American society, are not issues in the moral evaluation of performance-enhancing drugs because the different genetic endowments of individuals make inequality inevitable and fairness impossible to achieve.[9] Genetic endowment in terms of talent is seen as a given; some performers, whether athletes or musicians, "naturally" will be better players. Yet the work ethic reminds us: "Work hard and you shall be rewarded." Society respects the Horatio Alger personality, the persons who are able to pull themselves up by their bootstraps. All persons may not be equal in genetic endowment, so the reasoning goes, but all have equal opportunity to succeed.[10] The crucial factor in "success" (another American value) is hard work.

The meaning of unfairness in taking propranolol and other performance-enhancing drugs, then, lies in our cultural notions about success and the "right" way to obtain success - through hard work. Taking a drug to enhance performance suggests shortcutting the process of hard work. Its negative moral attribution is similar to others associated with such images as "queue jumping" and "taking the easy way out" to achieve a successful performance, instead of working hard for it. Ambiguity about performance-enhancing drugs is increased when images of cheating compete with other cultural messages that winning is everything, and that some forms of cheating (such as gaining the system in dealing with the IRS, customs agents, or insurance companies) are morally acceptable.

The image of cheating by using propranolol is juxtaposed with another cultural value, that of seeking to control the uncontrollable. Musicians believe that a good musical performance is achieved with talent and hard work, but is also dependent on a certain amount of luck. The perfomer and performance are subject to many uncertainties: the room temperature of the hall may be too cold or its acoustics may be poor; the performer may have stiff lip or finger muscles from practicing too long the day before; he or she may be suffering from a cold and not feeling well. Performance anxiety can be seen as one of the vagaries of performance. The physical and mental state brought on by uncontrollable axiety results, in missed notes, abnormal tone, and other qualities that detract from performance. Where talent ("genetic endowment") is seen as unchangeable and impossible to control or manipulate - at least with our present level of scientific knowledge - and hard work as a success factor depends on one's strength of character and drive to succeed, performance anxiety can now be controlled with a pill.

Medical Authority and the

Definition of Disease

To complicate this picture further, we can consider the role of medical authority in defining drug use and abuse. As physicians stand in the social role of gatekeeper here, the term abuse implies an acceptance of medicine's authority to define what is and is not proper drug use. Survey and anecdotal evidence shows that some musicians take propranolol without a prescription, and when they, not their physicians, deem it necessary. To the extent that such actions suggest a challenge to medical authority, they may add to the moral uncertainty some musicians have about propranolol use. While physicians who prescribe propranolol for performance anxiety are prescribing a drug that is not approved for that use by the Food and Drug Administration, their doing so is seen as "physician discretion" rather than "drug abuse. "

Medicine also has the power to define what is and what is not a disease. This power is important because drug use for treatment of disease is seen as legitimate use rather than abuse. Using prescription drugs for "nontherapeutic" purposes is deemed morally questionable.

What exactly is performance anxiety? Is it a psychiatric disease as defined by American psychiatric medicine? If so, then propranolol prescription by physicians and its use by musicians constitutes a legitimate use of the drug - to treat disease. The Diagnostic and Statistical Manual of Mental Disorders (DSM Ill-R) does not list "stage fright" or "performance anxiety" as a specific category, although certain features could be classified under the heading of either "social phobia" or "simple phobia." Although some musicians taking propranolol may exhibit a diagnosable psychiatric disease, the DSM III-R specifically states that "avoidance of certain social situations that are normally a source of some distress, which is common in many people with "normal" fear of public speaking, does not justify a diagnosis of Social Phobia."[12] One psychiatry textbook notes,

Performance anxiety or stage

fright includes symptoms of anxiety

which may escalate to episodes

of panic when public performance

is required. Many successful professional

performers routinely experience

panic attacks before performances.[13]

In the American Psychiatric Association's Treatments of Psychiatric Disorders, "performance anxiety" refers to anxiety associated with male sexual performance.[14] While a psychoanalytic connection between sexual performance and musical performance probably can be made by any amateur, a wider cultural connection can also be made. Performance is very important in American culture - it can relate to athletic performance, sexual performance, job performance, verbal performance, career performance - and conjures up our notion of success.

Although diagnosable cases of psychiatric disease that encompass performance anxiety probably exist and are probably being treated with propranolol and other therapies, it appears that some propranolol use by musicians occurs in order to treat normal anxiety associated with performance. The notion that some anxiety before a performance is "normal" is in itself a cultural construction and is related to our emphasis on performance success. The creation (by both medicine and society) of an entity called "performance anxiety" that musicians experience and that physicians treat with drugs is what some psychiatrists and anthropologists might can a "culture-bound syndrome."

Although some scholars argue that all illness is culture-bound, arising from specific cultural meanings and social circumstances, others argue that Western biomedical categories are universal disease categories into which all illnesses can be made to fit.[15] The notion of |culture-bound syndrome' or |culture-specific syndrome' is thus controversial, but generally refers to a cluster of symptoms that is culturally unique and is so bound up with its cultural meaning that it would not exist outside of the particular cultural context.[16]

The belief that so many people experience mild anxiety before public performance that such, anxiety can be considered normal or routine is an assumption arising from our sociocultural circumstances. But the characterization of this "normal anxiety" as a pathologic phenomenon in need of medical treatment is a culturally typical way of perceiving it. "Normal" behavior or life events are often controlled by reframing them as medical or pathologic events in need of medical therapy. Commonly cited examples of what has been called "cultural iatrogenesis" - medicine's usurption of peoples' ability to care for themselves, making them dependent on medical professionals and other "experts" - include the medicalization of birth and death, the use of drugs to treat "hyperactivity" in children, and the definition of alcoholism and drug abuse as diseases.[17] The redefinition of "normal" anxiety as the disease "performance anxiety" is also a form of cultural iatrogenesis. The message we are given is that "normal" feelings and emotions that are uncomfortable or distressing not only should be repressed, but that we can depend on medical experts to help us deal with such distress through the use of a medically prescribed drug.

Sorting Out Cultural Assumptions

Musicians' use of propranolol for performance anxiety highlights some of the conflicts and inconsistencies in the definitions we have and the values we hold about disease, drugs, and drug use. Recall the example of the trumpet player who takes propranolol before each of her performances. The ambiguity in this situation begins when we choose to describe what we see either as propranolol use for performance anxiety or propranolol use for performance enhancement. Each description encompasses a constellation of ambiguities, assumptions, and competing images, which shapes and ultimately constructs any ethical evaluation of propranolol use.

Unlike certain drugs that interfere with the user's autonomy, propranolol can be said to enhance autonomy by enabling the anxious performer to regain self-control. On the other hand, propranolol use for normal anxiety, the less-than-disabling kind, may evoke superimposed images of excessive use, dependency, and interference with autonomy-all images of drug abuse.

Taking a drug for performance enhancement elicits images of cheating because the individual is perceived as sidestepping the hard work needed to obtain success. But the work ethic also competes with what has been called the "instant coffee ethic": time-saving and labor-saving devices are valued in our rapid-paced, high-pressure life styles. The use of a drug for performance anxiety may be viewed by some people as faster and more economical than dealing with this condition through psychological or behavioral therapy, and therefore can be seen as a rational use of medication.
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Author:Slomka, Jacquelyn
Publication:The Hastings Center Report
Date:Jul 1, 1992
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