Performance anxiety

Several studies have reported the efficacy of p-blockers in the treatment of performance anxiety. Taken within 2 hours of a stressful event (e.g., an examination, a speech, or a concert), propranolol, 20-80 mg, may improve performance. A trial dose of 40 mg of propranolol should be administered before the performance situation in which the patient anticipates anxiety. This initial dose should not be taken in a high-risk or critical situation in which any unexpected side effect could have serious consequences. Subsequently, doses of 

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Blockers decrease physiologic symptoms of anxiety and are useful for reducing performance anxiety. Propranolol or atenolol should be administered 1 hour before a performance situation. 3-Blockers are not useful in generalized SAD.58... 

Psychogenic dysfunction occurs if a patient does not respond to psychic arousal. It occurs in up to 30% of all cases of ED. Common causes include performance anxiety, strained relationships, lack of sexual arousability, and overt psychiatric disorders such as depression and schizophrenia.5 It is postulated that the anxious or nervous man will have excessive stimulation of the sympathetic system, leading to smooth muscle contraction of arterioles and vascular spaces within erectile tissue.6 O Many patients may initially have organic dysfunction, but develop a psychogenic component as they try to cope with their inability to achieve an erection. It has been estimated that up to 80% of ED cases have an organic cause, with many having a psychogenic component as well.1... 

Causes of psychogenic ED include malaise, reactive depression or performance anxiety, sedation, Alzheimer s disease, hypothyroidism, and mental disorders. Patients with psychogenic ED generally have a higher response rate to interventions than patients with organic ED. 

Emotional manifestations include depression, performance anxiety, or embarrassment. 

Specific Sociai Anxiety Disorder, Acute Phase Treatment. Different strategies have evolved for treating specific social anxiety disorder versus generalized social anxiety disorder. Less complicated is the management of the specific subtype. Exposure-based psychotherapy is a mainstay of treatment, and as-needed medication doses prior to scheduled performances are also widely used. Preferred agents for performance anxiety are alprazolam or propranolol. 

P-Blockers commonly cause side-effects including bradycardia, hypotension, fatigue and bronchospasm. Overdose can cause fatal cardiogenic shock. Because of the doubtful evidence for efficacy and poor tolerability and safety, their use in anxiety disorders is Hmited. They may have a circumscribed role in the prevention of performance anxiety (Elman et al. 1998). 

Trazodone may cause priapism and enhance libido, and it prolongs nocturnal erections. This drug has been used both orally and by intracavemosal injection. It can be used alone or in combination with yohimbine. Overall, trazodone has not been as effective in treating ED as other available agents. However, it may be an option for selected patients, particularly those with performance anxiety or low libido. 

Despite very limited efficacy in most anxious patients, b-blockers may be useful for highly somatic individuals, such as those with performance anxiety. Antihistamines... 

Paradoxical intention focuses on staying awake as a means of diminishing performance anxiety. 

Propranolol reduces the frequency and intensity of migraine headache. Other 13-receptor antagonists with preventive efficacy include metoprolol and probably also atenolol, timolol, and nadolol. The mechanism is not known. Since sympathetic activity may enhance skeletal muscle tremor, it is not surprising that 13 antagonists have been found to reduce certain tremors (see Chapter 28). The somatic manifestations of anxiety may respond dramatically to low doses of propranolol, particularly when taken prophylactically. For example, benefit has been found in musicians with performance anxiety ("stage fright"). Propranolol may contribute to the symptomatic treatment of alcohol withdrawal in some patients. 

When tense, the muscles receive strong excitatory activation from the brain and, in turn, project excitatory activation back to it. When the tension is performance anxiety—as it so often is—the positive feedback loop that perpetuates the excitatory activation of the brain and muscles include the amygdala at the expense of the dorsolateral prefrontal cortex, which is not free to work its executive functions in an adaptive way. Hence memory may be blocked, decisiveness deferred, and creativity crippled. 

Beta-blocking drugs (eg, propranolol) may be used as antianxiety agents in situations such as performance anxiety. The sympathetic nervous system overactivity associated with anxiety appears to be satisfactorily relieved by the fblockers, and a slight improvement in the nonsomatic components of anxiety may also occur. Adverse central nervous system effects of propranolol include lethargy, vivid dreams, and hallucinations. 

SSRIs and MAOIs are effective in social phobia, -adrenoceptor blockers may also be helpful, particularly in performance anxiety, combating tremor and other symptoms of autonomic overactivity. 

Finally, patients must be in the proper mental frame of mind to be receptive to sexual stimuli. Patients who suffer from malaise, have reactive depression or performance anxiety, are sedated, have Alzheimer s disease, have hypothyroidism, or have mental disorders, commonly complain of erectile dysfunction. In most studies, patients with psychogenic erectile dysfunction generally exhibit a higher response rate to various interventions than do patients with organic erectile dysfunction, as their disease is often less severe. 

Affects men emotionally in many different ways (e.g., depression, performance anxiety, or embarrassment). 

For patients with psychogenic erectile dysfunction, psychotherapy may be used as monotherapy, or as an adjunct to specific treatments for the disorder. To enhance the relevance of psychotherapy, both the patient and his partner should be included in the counseling sessions. Also, treatment should be individualized and should address those immediate factors that may be causing performance anxiety or depression, rather than the remote, deep-seated reasons for psychological disorders. The effectiveness of psychotherapy is generally low, and long-term psychotherapy is often necessary. 

Ten small studies, some placebo controlled, consistently show benefit for situational/performance anxiety. 

Propranolol +++ TT Angina, HTN, post-MI, 1 migraine, tremor, performance anxiety, thyrotoxicosis... 

Sedation and sleep promotion can be achieved with drugs that are not classed as sedatives or hypnotics, including antihistamines (e.g., hydroxyzine) and opioid analgesics. Tricyclic antidepressants (TCAs) have been used in anxiety characterized by panic and/or phobias, and more recently the selective serotonin reuptake inhibitors (SSRIs) have been used. Propranolol has efficacy in performance anxiety and social phobias. 

Discrete performance anxiety (stage fright) most common phobia, treat with atenolol or propranolol (beta blocker) or paroxetine (SSR1)... 

The need for eros may also arise in situations that are not obviously relationship problems. For example, one sees many people who suffer from performance anxiety, and their dreams may be very instructive about how to overcome this. In one case, a woman was a gifted pianist but was too frightened to perform very often. After a period of suicidal depression, she dreamed that she was part of a traveling circus where she found comfort and security from her fellow performers. Her... 

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