Cerebrum Article

The Pressure to Perform

Assessing mental health risks for those in the public eye
Published: October 15, 2021
Author: Carl Sherman

Illustration by Daniel Hertzberg

One of the most memorable moments in last summer’s Tokyo Olympics was a star performance that didn’t happen. Shortly after a mistake in executing a difficult maneuver had cost her a medal—and threatened serious injury—gymnastic phenomenon Simone Biles announced that she was withdrawing from key competitions for mental health reasons. Despite returning several days later to take medals in some subsequent events, Biles was derided as a quitter by some. But upon the whole, the response was respect for her courage in protecting herself, and in going public with her mental health concerns.

Her example was not isolated. Two months earlier, second-seed Naomi Osaka withdrew from the French Open tennis tournament, citing the debilitating effects of stress and her struggles with depression. In recent years, public disclosures have made it clear that mental health problems are by no means uncommon among celebrity entertainers as well, a star cast that includes actors Jon Hamm, Kim Basinger, and Alec Baldwin, and singers such as Bruce Springsteen and Lady Gaga.

Are those who perform before the public—hundreds, thousands, even millions of spectators at a time—at heightened risk of mental illness? It’s complicated.

The mental health of athletes has received the most attention: There are international societies for sports psychiatry and sports psychology, and data for mental health conditions are far more abundant than for other fields. It is possible that problems are underreported due to concerns about image or remaining on the team. But among present and elite athletes, it appears that the prevalence of depression, anxiety, and other mental maladies is the same or just slightly higher than in the general population.

“The mental health [of athletes] is comparable to the public at large,” psychiatrist Carla Edwards of McMaster University summarizes. “But athlete-specific factors could place them at higher risk in some circumstances.

“[Mental health difficulty] can eke its way into sports in lot of different ways,” says Edwards,  president of the International Society for Sports Psychiatry. “Athletes can enter sports with pre-existing problems; or [problems] can develop as result of sport-related issues—such as pressure or maltreatment; arise independently; or be exacerbated by sports. A lot of athletes, conversely, need to keep sports incorporated into their lives for their mental health.”

Many of the same stresses are common to other endeavors in the glare of the spotlight. “Performance is performance is performance,” says Julliard psychologist Noa Kageyama. “The details may vary, but the basic principles are the same. All [performers] experience the same sorts of challenges.”

There may be differences between groups, however. Less robust data suggest that professional musicians suffer more than their share of depression and anxiety symptoms. A recent Norwegian study, for example, found that 18 percent of musicians within Norway reported significant psychological distress, compared to 8 percent of workers in other fields.

Stage Fright and Other Sorrows

Performers of all sorts are unquestionably subject to special challenges. Anxiety surrounding the performance itself—“stage fright”—is the most obvious. This has been most studied in musicians. Various studies have suggested that between 15 and 70 percent of professional musicians report performance anxiety. “These statistics are probably on the low end—every musician gets a little nervous before every performance,” says Kageyama. “It’s a matter of degree, whether they feel their nerves are derailing their performance, or a useful adjunct.”

Attempting to control anxiety can itself be a problem. A 2015 survey of 447 players conducted by the International Society of Symphony Orchestra Musicians found that 70 percent had used beta blockers, cardiac drugs that blunt the physiological response to anxiety. In extreme cases, performance anxiety can end a career. “A lot of musicians are talented enough but can’t make it performance-wise,” says psychiatrist David Shapiro, of Weill Cornell Medical College. “Anxiety leads to avoidance, and they miss gigs or are repeatedly unable to get to jobs on time.”

Severe stage fright crippled singer-songwriter Carly Simon’s career, kept singer Adele from touring, and drove Vladimir Horowitz, one of the great classical pianists of the last century, off the concert stage for decades.

Fear of public failure is at the heart of performance anxiety, and its severity can depend on the nature of the performance (e.g., solo vs. orchestral) and the size of the audience. But while a violinist may feel peak stress when picking up his or her bow before a packed concert hall, many musicians “are not that nervous in front of an audience of strangers, as opposed to teachers, fellow musicians, or friends and family members” whose negative evaluation would carry a special sting, says Kageyama.

Some anxiety in the heat of athletic competition is inevitable (“I don’t think you’re human if you don’t get nervous,” according to hockey great Sidney Crosby), but stage fright per se tends to be less problematic in sports, says Edwards. “Athletes on a high-performance pathway from an early age are exposed to larger and larger crowds… When they’re in their element and know that they’re good at it, the anxiety is not there.

“Even for some athletes with social anxiety—they hate to go to parties—performing in front of 10,000 people is not an issue. They don’t worry about it at all.”

In any case, the performance itself is only part of the story, and not necessarily the biggest part. A more substantial threat to mental health may come outside the arena and off the stage.

“The way the general public views elite athletes is that they have ‘the life.’ They just get to play sports,” says Edwards. “They don’t understand that’s the tip of the iceberg, and in the submerged part is all of the other things that contribute to challenges and pressures.”

It starts early. Elite athletes and musicians frequently excel from their first years, and training and performance may dominate and destabilize their childhood, disrupting family relationships and schooling. Young performers can be subject to pressure from parents and others who identify too closely with and exploit their success—the “achievement by proxy distortion.” Stage mothers (and fathers) have their equivalent in the worlds of sport and music.

The lives that many star entertainers, elite athletes, and virtuoso musicians lead entail years of sustained stresses and pressures, which can include frequent travel and irregular hours, disturbed sleep, and rigorous training or practice schedules. Invasion of privacy comes with the territory, and personal relationships may be strained. “Celebrity can be a mental health risk factor if the person is not psychologically healthy enough before becoming a celebrity,” says Beverly Hills psychiatrist Carole Lieberman, who has worked with actors and other performers and as a consultant in the entertainment industry.

Those in the public eye have always had to deal with audience catcalls and bad press. But the internet puts such assaults on steroids: You’re performing—and living—before an often vociferous public of millions, not thousands. “Social media amplifies the effect of criticism,” says psychologist Michael Hollander of McLean Hospital and Harvard. Failure in competition, or personal disclosures (like Biles’s and Osaka’s concerns about their mental health) can unleash a barrage of vicious commentary that reverberates for weeks or months. “You’re a victim of these comments, and you can’t fight back,” says Hollander. “I think the impact of that shouldn’t be undersold.”

In the pandemic, performers faced the same mental health challenges as everyone, with an extra burden all their own.

“[Covid] cut off access to training,” says Edwards, speaking of the 2021 Olympics. “Athletes always measure themselves against their former selves—they expect to perform as well or better. If they aren’t able to train as much as before, it plants seeds of doubt.” Connection to their programs, teammates, and coaches normally girds athletes’ mental health, she says.  Those who were forced to train in isolation lost those supports.

For musicians and entertainers, as well as athletes, the inability to do their thing in front of live audiences, for months on end, has been emotionally taxing, Kageyama says. Now that concert and other venues are reopening, “it’s been difficult for many to get back into performing. Musicians fear being out of rhythm, out of practice. ‘Getting back on the horse’ has been a source of additional stress and anxiety.”

While star performers may turn to alcohol and drugs to cope with the pressures of their lives, relieve physical pain, or improve performance, the extent of misuse is unclear. “It is hard to know whether entertainers have more substance abuse than others,” says Lieberman, “but the fact that their overdoses and partying make headlines gives us the impression that they do.” (Witness the very public meltdowns of stars like Britney Spears and tragic deaths of singers Amy Winehouse and Prince.)

There is limited evidence that athletes are more prone to substance problems than the general population, and several studies suggest that celebrities in general are at increased risk of addiction. One analysis of drug-related deaths among famous people found more than half involved entertainers, with athletes the next best represented.

Performance and the Brain

From a neurobiological perspective, the performer’s life is a study in stress. “Our current stress system developed 10-20,000 years ago. It evolved to escape the Smilodon (extinct saber-tooth cat), not to worry about how we would look in front of 40 million people,” says Gerard Sanacora, professor of psychiatry and director of the Yale Depression Program. “An athlete [or other performer] isn’t going to die from putting in a poor performance and getting booed, but the brain perceives it as a threat.”

The dual nature of stress is on full display. “There’s a spectrum from adaptive to toxic, but it’s all the same system,” he says. “When appropriate to changes in the environment, the stress response is positive; it increases cognitive functioning and carries over into enhanced psychomotor, physical activities.” Musicians and athletes know that enhanced arousal is a vital ingredient for vigorous, skilled performance.

“But past that, the downside of the curve becomes evident,” he says. Neuroplasticity—the ability of nerve cells to form and change connections—increases in some areas and declines in others. Reduced growth factor in hippocampal and cortical regions may inhibit working memory. The release of the excitatory neurotransmitter glutamate is critical to how the brain adapts, but at high levels can have a detrimental effect.

“With too great intensity, or prolonged intensity over time, [stress] can contribute to pathophysiologic changes in brain processing, even to the development of the behaviors and emotions we call depression,” Sanacora says. A number of alterations typical in the depressed brain—e.g., reduced hippocampal and prefrontal cortex volume and synaptic density, increase in inflammatory markers—can be related to the effects of chronic stress.

On the immediate level, stress can invade performance, posing physical risks: A 2021 meta-analysis of 18 papers suggested that stress—both surrounding competition and in other aspects of their lives—along with anxiety and, to a lesser extent, depression, increased the risk of injury to athletes including football players, gymnasts, runners, soccer players, and swimmers.

The effect on performance quality is more evasive: studies of its association with anxiety, for example, are inconsistent. “Athletes talk about their optimal zone of functioning; chronic stress makes it hard to get there, which can undermine their confidence,” says Edwards.

For musicians, “the most distressing effect of anxiety is a loss of accuracy—intonation, rhythm, quality of sound,” says Kageyama. “Not as noticeable to an audience as to the performer himself is a tendency to play much more cautiously—not taking risks. Instead of going for high-climax moments, everything is a little more muted; there’s a drastic difference in expressiveness.”

What happens in the performer’s brain, and how stress and anxiety might disrupt it, are far from clear. But it is evident that the skilled movements of sport and artistic performance demand an intricate choreography of events connecting diverse brain regions.

Kathleen Cullen, whose research has focused on “how we move through the world in the face of gravity,” says that in executing complex actions while maintaining balance—as demanded by sports such as gymnastics and basketball and artistic pursuits such as dance—“the brain is computing the sensory input it expects and then comparing it with the sensory feedback it actually receives, combining information from multiple systems.”

The vestibular system [a kind of gyroscope/accelerometer based on signals from the inner ear] “tells with great precision how the head is moving through space. The proprioceptive system [which tallies input from muscles throughout the body] tells you how limbs are positioned, relative to the body,” says Cullen, professor of biomedical engineering, neuroscience, and otolaryngology at Johns Hopkins University,

These signals come through the spinal cord and converge in the cerebellum, “where the brain computes its prediction based on an internal model of sensory flow…. when there’s a difference between proprioceptive and vestibular input and what the brain expects, there’s an error signal, which the athlete can then correct on the fly.” The cerebellum also receives signals from the ventral striatum, bringing in higher-level cognitive functions. All this happens within milliseconds, she says.

More generally, the brain’s comparison of an internal model deeply entrenched by the motor learning of endless practice, and the sensory input of the act itself, underlies highly skilled performance. To pitch a cut fastball in baseball with pinpoint precision or execute flawless vibrato on the violin, “you certainly need an intimate relationship in terms of movement and expected feedback,” she says.

How things go wrong is an ongoing area of research, Cullen says. But given the complex orchestration of brain processes, it’s no small surprise that overarousal creates problems. “What skilled athletes and musicians do are voluntary movements. Cortical areas such as the medial prefrontal cortex encode higher levels of representation and the importance of certain motor behaviors. When the stakes are higher, you pay more attention; but if the stress level gets too high, it can get counterproductive, interfering with the volitional component of movement and flipping you into a reflex, reactive mode. You lose focus on where you are; anxiety becomes a distraction from what you’re trying to do.”

A Silver Lining?

The dark side of performers’ lives may enlighten the public at large about mental health and illness. “Fifteen years ago, people didn’t talk about this,” says Katrina Gay, chief development officer at National Association for the Mentally Ill. “When athletes and elite influencers share their journey, it encourages people in their own struggles with mood disorders and anxiety.  It encourages them to seek help.”

The willingness of an admired figure like Simone Biles to make substantial sacrifices for her mental well-being inspires others to do likewise, says Gay. “I’ve noticed more people willing to take a time-out, a mental health break from their own work.”

The power of example may be particularly important for groups reluctant to seek help for mental health problems, such as men and racial minorities. A 2020 paper in Academic Psychiatry cited the example of wrestler/action movie star Dwayne “The Rock” Johnson, who has talked openly and tweeted about his depression. “You are not alone,” he told his millions of followers.

Kevin Love, a five-time National Basketball Association All-Star, also inspired countless performers and others when he began advocating for mental health awareness after suffering a panic attack during a game in November 2017. His powerful essay for the Players Tribune in 2020 about living with anxiety and depression has helped remove the stigma about seeking treatment that has long plagued high-profile performers.

“Talk to somebody. You would be amazed at how freeing it is just to talk to somebody and tell them the truth about what you’re going through. And listen, I’m not trying to sell you some fairy-tale version of mental health. It took me years and years—hell, it genuinely took 29 years for me to realize what I needed.

I needed medication. I needed therapy. I still need those things now, and I probably always will.”

This article first appeared in the Fall 2021 issue of our Cerebrum magazine. Click the cover for the full e-magazine.