Performance anxiety and stage fright

The short answer

Almost everyone gets nervous before a big talk. Performance anxiety is when that fear is strong, lasting and gets in your way: you turn down chances to speak, struggle through presentations in panic, or avoid jobs and courses because of it.

Doctors use the American DSM-5 manual to describe a “performance only” type of social anxiety disorder. It applies when the fear is limited to speaking or performing in public, and you are fine in everyday conversations, parties or eating in front of others.

What it feels like

The body often leads: a shaking voice and hands, a pounding heart, sweating, a dry mouth, a mind that goes blank. Thoughts follow: “They can see I’m shaking.” “I’ll forget everything.”

You are probably more visible to yourself than to the audience. In a set of experiments, people kept overestimating how much others noticed their embarrassing moments. Listeners usually see far less of your nerves than you feel.

Is it a separate thing from social anxiety?

Partly. The “performance only” label replaced the older “generalized” label when the DSM-5 came out in 2013.

But research suggests performance fear and other social fears are closely linked:

• A large US survey of adults found that fears of performing and fears of interacting with people seemed to form one shared fear, not two separate ones.
• In a large survey of US teenagers, the performance-only type was rare. Most teenagers with social anxiety had the general form.

So if your fear started with presentations, check honestly whether it also shows up in meetings, phone calls or small talk. If it does, the guides on social anxiety in general apply to you too.

Stage fright in musicians, athletes and others

Performance anxiety is also common in music, sport and acting, where people perform for a living. Much of the research there uses different methods and is not about the clinical disorder. The core advice is similar: practise in front of people, step by step, and stop relying on tricks that keep the fear alive.

What helps

Practice in front of people, step by step

Exposure, facing a feared situation on purpose in small steps, is the core of treatment. It works best when you drop your safety behaviours, such as reading every word from a script or never looking up. See exposure on your own and public speaking.

Virtual reality

Practising in front of a virtual audience is a tested option for this fear. In a trial of 97 people whose main fear was public speaking, 8 sessions of VR exposure therapy and 8 sessions of group exposure therapy both helped more than waiting. They helped about equally, and gains lasted a year. In another trial, even one session of therapist-led VR practice reduced public speaking fear compared with waiting. VR makes it easy to start with a small, friendly audience and build up. See VR exposure therapy.

Therapy

Cognitive therapy for social anxiety uses practice speeches, video feedback and dropping safety behaviours. It is one of the best-supported therapies for social anxiety disorder.

Propranolol and other beta-blockers

Many people take a beta-blocker such as propranolol before a talk. It blocks some of adrenaline’s effects on the body: shaking, a racing heart. On forums, people often report that it stops the shaking but not the worried thoughts.

The trial evidence is thin. A review found only one trial of propranolol for social phobia, with 16 people. It judged the evidence not good enough to support routine use. Canadian guidelines list propranolol as not recommended for the general form of social anxiety disorder. It may still have a place for occasional performance situations. Talk to a doctor: beta-blockers are not safe for everyone, for example people with asthma or some heart conditions. See propranolol.

When to get help

If fear of speaking or performing is shaping your choices of study or work, it is worth treating. Start with the start here guide or talking to your doctor.