Propranolol for Performance Anxiety
For performance anxiety, propranolol is most effective at doses of 20-40 mg taken 1-2 hours before the anxiety-provoking event. This dosing regimen provides optimal relief of somatic symptoms like tremor and palpitations while minimizing side effects 1, 2.
Dosing Guidelines
- Standard dose: 20-40 mg taken 1-2 hours before performance
- Frequency: Single dose as needed before anxiety-provoking events
- Maximum daily dose: Generally not exceeding 40 mg for performance anxiety
Mechanism and Effectiveness
Propranolol works primarily by blocking peripheral beta-adrenergic receptors, reducing physical symptoms of anxiety such as:
- Tremor
- Palpitations
- Tachycardia
- Sweating
Research shows propranolol is particularly effective for performance anxiety when somatic symptoms are prominent but not extreme 3. A study examining propranolol's effects on public speaking demonstrated that 40 mg significantly reduced observable anxiety in anxious subjects 2.
Comparative Efficacy of Different Doses
A double-blind randomized clinical study comparing 20 mg and 40 mg doses found:
- Both doses effectively reduced anxiety
- 20 mg provided significant anxiety reduction with fewer side effects
- 40 mg was associated with higher rates of bradycardia (25%) and hypotension (10%) 4
Administration Considerations
- Take with or after food to reduce the risk of hypoglycemia
- Avoid taking during periods of diminished oral intake or vomiting
- Consider lower doses for patients with:
- Cardiovascular conditions
- Respiratory disorders
- History of hypotension
Precautions and Contraindications
Before prescribing propranolol for performance anxiety, assess for:
- Asthma or obstructive airway disease
- Bradycardia or heart block
- Hypotension
- Diabetes (risk of masking hypoglycemic symptoms)
- Concurrent medications that may interact with propranolol
Common Side Effects
- Fatigue
- Dizziness
- Sleep disturbances
- Nausea
- Cold extremities
Clinical Pearls
- Propranolol is more effective for physical symptoms of anxiety than psychological symptoms
- Effects are typically noticed within 1-2 hours of administration
- Unlike benzodiazepines, propranolol does not cause sedation or dependence
- Some patients may experience cognitive effects, though these are typically minimal at the doses used for performance anxiety 2
For most patients with performance anxiety, a single 20 mg dose taken 1-2 hours before the anxiety-provoking event provides the optimal balance between efficacy and side effect profile 1, 4.