The Dr. Is In: Performance Anxiety

The Dr. Is In: Performance Anxiety

Managing performance anxiety is a challenge for many singers. Dr. Jahn shares his perspective as a laryngologist on the mind-body connection, preparedness, and the placebo effect—and how they relate to anxiety.


​​A certain amount of anxiety is normally associated with performance. How can it be otherwise? Even .after decades attending hundreds of concerts, operas, and recitals, we still find the thought of an opera singer standing on stage, performing a long and technically difficult work from memory, often in a foreign language, in front of thousands of critical listeners, an incredible physical and psychological feat.

Anxiety is a real issue for most singers, no matter their level of preparation. In the words of tenor Roberto Alagna, “A real artist is never comfortable.” The sentiment echoes Enrico Caruso, who put it more bluntly: “An artist who boasts he is not nervous is not an artist; he is a liar or a fool.”  And certainly, a comfortable singer giving a complacent performance is not someone who can meaningfully connect with the audience.

As with other psychological issues, anxiety can be situation appropriate or an intrinsic personality trait. For example, concerns about having to perform while ill, having to sing music that is not fully prepared, or working with an unsupportive conductor would be legitimately anxiety provoking. However, general issues of self-doubt or lack of worth are possibly underlying personality traits that can spill over and color a performance.

Even for laryngologists, a significant part of our practice is managing anxiety. In the performing arts, the mind-body connection is particularly powerful, and every physical complaint carries with it a psychological issue that needs to be addressed. Conversely, excess anxiety or depression will at times somaticize—i.e., manifest as a physical complaint. Either way, the complete management of singers involves accepting this reality. I have concerns about physicians who dismissively tell their patients, “There is nothing wrong with you; it’s all in your head.” They ignore the reality and the impact that psychological issues such as anxiety can have on the voice and, in my opinion, do not fully address the problem at hand.

There are many strategies to dealing with performance anxiety. First, you need to be aware of, and control, every aspect of the performance. Most obviously, you need to know your material! To thoroughly know the music and the words is the first building block of confidence, and that commitment to memory needs to be so ingrained that it can withstand any unexpected mishap on stage. Next, in a staged performance, be aware of every aspect of the staging. This means not only that you understand the physical aspects of where to stand and where to move, but also think about, and anticipate, where possible problems may occur. Complete comfort on stage—whether singing, moving about, or any other stage action—is fundamental to reducing performance anxiety.

It also helps to have a “Plan B”: What if? This requires thinking on your feet, being ready to instantly adjust the performance if the need arises. Singers performing while sick frequently take the last note down an octave or modify their ornamentation. Confidence is often gained as the performance progresses. The voice needs to last the entire performance, and we often hear singers holding back in the first act or saving their energies for bigger and more exposed solos, especially if it’s their first time on a large and unfamiliar stage.

To seek meaning and to impose order on the world around us is a basic human need. This allows events to appear more predictable and less frightening. The mind does this by arbitrarily imputing significance to objects and events, which gain power and importance in the process. Superstition, ritual, and the placebo effect are the result of this way of thinking, and these are all potentially useful in the reduction of anxiety for many performers. 


For example, in the opera world it was generally known that Pavarotti would not perform until he found a bent nail. That bent nail was his confidence-building “sign” that he would sing well. Consequently, on performance nights the stage crew made sure to scatter a few bent nails around the ground backstage. I also once treated a European soprano who was told that she needed to get her allergy shot every night “after the first act.” Of course, there is no medical reason for this, but the placebo effect was powerful and important in maintaining her confidence. On a less dramatic level, many singers have special articles of clothing or jewelry that give them “good luck.” The dressing room table often holds familiar objects or photographs that generate positive energy and build confidence.

The problem with the placebo is that it must be accepted and used in an unquestioning fashion. Once you try to question its effect, it disappears. For this reason, we should incorporate this powerful and positive aspect of the mind and use it to strengthen confidence and reduce anxiety. But that does not mean that everything else that can be controlled and anticipated can be neglected. The placebo works best when the performer has mastered every aspect of the performance.

As a final note, the use of medications to reduce anxiety should be mentioned. Stage fright can be much improved with the use of beta blockers, such as Inderal. This medication reduces heart rate and allows many overly anxious performers (whether singers or instrumentalists) to get through the show. It does, however, take away some of the “excitement” of the performance—an excitement that comes from accepting and channeling anxiety in a positive way.

Anthony Jahn, M.D.

Anthony Jahn M.D. is an otolaryngologist with a subspecialty interest in ear diseases, disorders of hearing and balance, and disorders of the voice. He is a professor of clinical otolaryngology at Mount Sinai School of Medicine and is the noted author of Care of the Professional Voice. For more resources, go to his website