Public Speaking Anxiety Medication
For performance-limited social anxiety (public speaking anxiety), SSRIs—specifically paroxetine, escitalopram, or sertraline—are the recommended first-line pharmacotherapy, with beta-blockers like propranolol reserved for as-needed use in specific performance situations. 1
First-Line Treatment: SSRIs
Selective serotonin reuptake inhibitors (SSRIs) are the primary recommended pharmacotherapy for social anxiety disorder, including performance-limited presentations like public speaking anxiety. 1
Specific SSRI Options:
Paroxetine 20-50 mg/day is highly effective, with 55% of patients achieving "much improved" or "very much improved" status compared to 24% with placebo, and produces a 39% reduction in social anxiety symptoms. 2
Escitalopram is an approved first-choice option that helps with anxiety symptoms and is well-tolerated. 1, 3
Sertraline demonstrates equivalent efficacy and tolerability to paroxetine, with both producing approximately 56-57% reductions in anxiety scores. 1, 4
Dosing Strategy:
Start with 20 mg/day of paroxetine or equivalent SSRI dose, as this is the recommended starting dose with proven efficacy. 5
Increase in 10 mg increments weekly if needed, up to a maximum of 50 mg/day for paroxetine (or equivalent for other SSRIs). 2, 5
Allow 6-8 weeks at therapeutic doses before determining treatment failure, as onset of effect is delayed due to adaptive changes in serotonergic receptors. 3, 6
Alternative Pharmacotherapy
Beta-Blockers (As-Needed Use):
Propranolol can be used for situational performance anxiety when anxiety is limited to specific public speaking events rather than generalized social situations. 7
This approach is best suited for infrequent, predictable performance situations rather than chronic treatment. 1
Other Medications with Limited Evidence:
Benzodiazepines (e.g., clonazepam) have shown efficacy but carry dependence risk and are not included in primary guideline recommendations. 1, 8
Venlafaxine (SNRI) is suggested as an alternative with similar efficacy to SSRIs, though evidence is weaker (GRADE 2C). 1
Gabapentin and pregabalin have demonstrated efficacy in double-blind studies but lack strong guideline support. 8
Important Clinical Considerations
Tolerability Profile:
Common SSRI side effects include nausea (18-25%), headache, somnolence, dry mouth, and insomnia, but these are generally well-tolerated. 6, 2
SSRIs do not cause dependence and are safer in overdose compared to tricyclic antidepressants or benzodiazepines. 6
Sexual dysfunction may occur and should be discussed with patients. 6
Monitoring Requirements:
Watch for serious adverse reactions including serotonin syndrome and neuroleptic malignant syndrome, though these are rare. 1
Evaluate anxiety symptoms separately at each visit to determine treatment efficacy. 3
Assess for treatment-emergent anxiety during the first 1-2 weeks, as initial SSRI administration may temporarily worsen anxiety before improvement occurs. 6
Common Pitfalls to Avoid
Do not switch medications prematurely—allow the full 6-8 week trial at therapeutic doses before declaring treatment failure. 3
Do not use benzodiazepines as first-line therapy despite their rapid onset, due to dependence potential and lack of guideline support for this indication. 1
Do not rely solely on beta-blockers for chronic social anxiety—these are appropriate only for situational, performance-limited anxiety. 1
Do not overlook the distinction between performance-limited and generalized social anxiety disorder, as this affects treatment selection and prognosis. 1