What is the typical dosing for propranolol (beta blocker) in treating performance anxiety?

Propranolol Dosing for Performance Anxiety

For performance anxiety, propranolol 10-40 mg taken as a single dose 30-60 minutes before the anxiety-provoking event is the standard approach, with 40 mg being the most commonly studied and effective dose. 1, 2

Recommended Dosing Strategy

The typical regimen is propranolol 40 mg administered once, 1 hour before the performance or anxiety-provoking situation. 1 This single-dose approach has been objectively validated in students taking standardized tests, where 40 mg propranolol given one hour before testing resulted in mean score improvements of 130 points on the SAT compared to baseline performance without medication. 1

Dosing Range and Titration

• Lower doses of 20-40 mg once to three times daily are effective for anxiety disorders characterized by prominent somatic symptoms. 3
• For acute performance anxiety specifically, a single 40 mg dose is preferred over chronic dosing. 2
• Improvement occurs within 1-2 hours of administration, making it ideal for situational use. 4
• Some patients may require doses ranging from 10-40 mg depending on symptom severity and individual response, though 40 mg represents the most studied dose. 3, 2

Patient Selection Criteria

Beta-blockers are most effective for performance anxiety when somatic/autonomic symptoms predominate (tremor, palpitations, tachycardia, sweating) rather than purely cognitive anxiety symptoms. 5, 4

Ideal Candidates

• Individuals with tremor during public speaking or musical performance 4
• Those with palpitations and tachycardia during anxiety-provoking situations 4
• Students experiencing test anxiety with cognitive dysfunction 1

Poor Candidates

• Patients with severe panic attacks (beta-blockers work better for mild-to-moderate symptoms) 4
• Those with purely psychological anxiety without prominent physical symptoms 4

Mandatory Pre-Treatment Assessment

Before prescribing propranolol, exclude absolute contraindications including second or third-degree heart block, decompensated heart failure, asthma or reactive airway disease, and hypotension. 6, 7

Required Baseline Evaluation

• Heart rate and blood pressure measurement 6, 7
• Cardiovascular examination with auscultation 6
• History screening for bronchospasm, diabetes, and concurrent medications affecting cardiac conduction 6

Note that routine blood work, ECG, or echocardiogram are NOT required in otherwise healthy adults without cardiac concerns. 6

Critical Safety Considerations

Common Pitfalls to Avoid

Never abruptly discontinue propranolol after chronic use, as this can precipitate rebound hypertension, tachycardia, or angina. 6 However, for single-dose performance anxiety use, this is not a concern.

Propranolol may mask hypoglycemia symptoms in diabetic patients. 6 Exercise caution and counsel patients accordingly.

Monitor for hypotension and bradycardia, particularly if patients inadvertently take higher doses or use it more frequently than intended. 6, 7

Adverse Effects Profile

• Fatigue, bradycardia, hypotension, dizziness, and cold extremities are the most common side effects 6
• Potential cognitive impairment remains controversial, though one study showed impaired recall of difficult memory items in anxious subjects taking 40 mg 2
• Depression in predisposed patients is possible but uncommon 3

Duration of Treatment

For performance anxiety, propranolol is used on an as-needed basis before specific events rather than as chronic daily therapy. 3, 4 The clinical efficacy of beta-blockers for anxiety beyond 4 weeks of continuous use remains unproven. 3

Practical Algorithm

1. Confirm diagnosis: Performance anxiety with prominent somatic symptoms (tremor, palpitations, tachycardia)
2. Screen for contraindications: Asthma, heart block, heart failure, severe bradycardia
3. Obtain baseline vitals: Heart rate and blood pressure
4. Prescribe: Propranolol 40 mg to take 1 hour before the anxiety-provoking event 1
5. Counsel patient: Take on empty stomach or with light food, expect effect within 1-2 hours 4
6. Adjust if needed: May reduce to 20 mg if side effects occur, or increase to 80 mg if inadequate response (though this is less well-studied) 3