Propranolol for Public Speaking Anxiety
Propranolol 20-40 mg taken 1 hour before public speaking is an effective and appropriate treatment for performance anxiety, specifically targeting the physical symptoms of stage fright such as tremor, rapid heart rate, and nervousness. 1
Clinical Rationale
Propranolol works by blocking peripheral beta-adrenergic receptors, thereby reducing the physical manifestations of adrenaline release during performance situations—specifically rapid heart rate, tremors, and visible nervousness. 1 This mechanism makes it particularly suited for situational performance anxiety rather than chronic anxiety disorders. 2
Evidence Supporting Use
Objective performance improvement: A controlled study in students with test anxiety demonstrated a mean 130-point improvement in SAT scores when taking 40 mg propranolol one hour before testing compared to their baseline performance (p < 0.01). 3
Reduction in observable anxiety: Propranolol 40 mg significantly reduced rated anxiety in non-verbal behavior and speech performance of anxious subjects during public speaking tasks, while also decreasing pulse rate. 4
Established clinical practice: Multiple guidelines recognize propranolol's utility for performance anxiety and stage fright, with the American College of Cardiology specifically recommending it for surgeons experiencing procedural anxiety. 1
Dosing Protocol
- Single-dose strategy: 20-40 mg taken 1 hour before the performance event 1
- Not for chronic use: This is situational therapy, not daily maintenance treatment 1
- No need for titration: Single-dose administration does not require gradual dose escalation
Important Limitations and Context
When NOT to Use Propranolol
Propranolol is absolutely contraindicated in patients with: 1
- Asthma or chronic obstructive pulmonary disease
- Bradycardia or heart block
- Decompensated heart failure
- Severe hypotension
Special Precautions
- Diabetes: Use with caution as propranolol may mask hypoglycemic symptoms 1, 5
- Avoid abrupt discontinuation: If used regularly (not typical for performance anxiety), do not stop suddenly due to rebound risk 1, 5
- Potential cognitive effects: Some evidence suggests propranolol may impair recall of difficult memory tasks in anxious individuals, though this effect appears modest 4
Comparison to Other Approaches
Not First-Line for Generalized Anxiety
The Canadian Clinical Practice Guidelines and Japanese guidelines deprecate propranolol for chronic social anxiety disorder, recommending SSRIs/SNRIs as first-line pharmacotherapy for generalized social anxiety. 6, 1 Beta-blockers are specifically noted as having negative evidence for chronic anxiety treatment. 6
Cognitive Behavioral Therapy Alternative
For chronic performance anxiety (not situational public speaking), CBT shows superior outcomes with statistically significant reductions in subjective anxiety and improved performance quality in musicians with performance anxiety. 7 However, for isolated, infrequent public speaking events, the single-dose propranolol approach is more practical than a multi-session therapy program.
Clinical Algorithm
For situational public speaking anxiety:
- Screen for contraindications (asthma, heart block, bradycardia, heart failure) 1
- If contraindications present → consider CBT or alternative approaches 7
- If no contraindications → prescribe propranolol 20-40 mg to take 1 hour before event 1
- Advise trial dose before important event to assess individual response and tolerability
For frequent or chronic performance anxiety:
- Consider CBT as first-line treatment 6, 7
- If pharmacotherapy needed chronically → SSRIs/SNRIs, not beta-blockers 6, 1
Common Pitfalls to Avoid
- Do not prescribe for daily use in performance anxiety—this is situational therapy only 1
- Do not use as treatment for generalized anxiety disorder—SSRIs are first-line 6, 1
- Screen respiratory history carefully—missing asthma/COPD contraindication is dangerous 1
- Warn diabetic patients about hypoglycemia masking 1, 5