Propranolol Dosing for Performance Anxiety
For performance anxiety, propranolol should be dosed at 20-40 mg taken 1-3 times daily, with a single dose of 40 mg taken approximately one hour before a performance being most effective for situational anxiety. 1, 2
Dosing Guidelines
- The typical dose range for propranolol in treating performance anxiety is 20-40 mg, administered once to three times daily depending on the duration of anxiety symptoms 1
- For situational performance anxiety (such as public speaking, musical performances, or test-taking), a single 40 mg dose taken approximately one hour before the event is most effective 2
- Lower doses are typically used for anxiety compared to cardiovascular indications, with baseline assessment of heart rate and blood pressure recommended before starting treatment 3
- The clinical efficacy of beta-blockers for anxiety when administered for periods longer than 4 weeks remains to be demonstrated 1
Mechanism and Effectiveness
- Propranolol primarily works by blocking peripheral adrenergic beta-receptors, most effectively relieving somatic symptoms of anxiety such as tremor and palpitations 4
- Improvement in anxiety symptoms is typically noted within 1-2 hours of administration, even with relatively low doses 4
- In a study of students with test anxiety, a single 40 mg dose of propranolol taken one hour before the SAT resulted in scores that were 130 points higher compared to testing without medication 2
- Beta-blockers are particularly useful for anxiety characterized by somatic symptoms related to increased adrenergic tone 1
Administration Considerations
- Propranolol should be administered with food to reduce the risk of hypoglycemia 5
- Monitoring for hypotension and bradycardia is advised, especially at higher doses 5, 3
- Baseline cardiovascular assessment is recommended before initiating propranolol 5
Contraindications and Precautions
- Propranolol is contraindicated in patients with asthma, obstructive airway disease, decompensated heart failure, second or third-degree heart block, and history of hypoglycemic episodes 5, 3
- Abrupt discontinuation should be avoided to prevent rebound hypertension or tachycardia 5
- Propranolol may mask symptoms of hypoglycemia in susceptible patients 5
- There is some controversy regarding potential cognitive impairment with propranolol use, with some studies showing greater central effects at lower doses (40-80 mg) than at higher doses (160-320 mg) 6
Long-term Use Considerations
- For chronic anxiety treatment, dosages of 80-320 mg daily have been used, but requirements typically diminish over time 7
- Beta-blockers are useful adjuncts to existing treatments for anxiety and may be particularly valuable now that benzodiazepines are being avoided due to dependence risks 4
- Depression, which may be present in anxiety patients, usually improves with propranolol but may persist in some cases and require additional treatment 7