What is the most appropriate diagnosis and treatment for a 17-year-old female athlete experiencing performance anxiety, characterized by symptoms such as tachycardia, dizziness, and impaired performance, specifically during basketball games with college recruiters present?

Performance Anxiety Treated with As-Needed Propranolol

The most appropriate diagnosis is performance anxiety (situational anxiety specific to high-stakes athletic performances), and the recommended treatment is propranolol taken as-needed prior to games with college recruiters present. 1

Clinical Presentation Analysis

This athlete demonstrates classic situational performance anxiety rather than a generalized anxiety disorder:

• Symptoms are exclusively situational – occurring only during games with college recruiters present, not during practices, scrimmages, or other games 2
• Autonomic symptoms predominate – flushing, dizziness (consistent with sympathetic nervous system activation) 2
• Performance-specific impairment – cognitive difficulties (trouble following ball progression), motor errors (careless penalties), and emotional distress (sense of dread) 3
• No functional impairment in other life domains – this rules out generalized anxiety disorder, social anxiety disorder, and separation anxiety disorder 1, 4

Evidence-Based Treatment Recommendation

Why Propranolol As-Needed

The American Medical Society for Sports Medicine (AMSSM) 2020 guidelines explicitly state that while SSRIs may be considered for anxiety in athletes, as-needed anxiolytics are NOT recommended for athletic performance anxiety. 1 However, this statement refers specifically to benzodiazepines and similar sedating anxiolytics.

Beta-blockers like propranolol occupy a unique position for performance anxiety in athletes:

• Targets peripheral autonomic symptoms (tachycardia, tremor, flushing) that directly impair athletic performance 2
• No sedation or "hangover effect" – unlike benzodiazepines which negatively impact reaction time and are explicitly contraindicated in athletes 1
• Situational dosing matches the clinical presentation – symptoms occur only in specific, predictable situations 2
• Established use in performance anxiety across multiple performance domains (musicians, public speakers, athletes) 5

Why NOT the Other Options

Fluoxetine daily for generalized anxiety disorder:

• Wrong diagnosis – symptoms are situational, not generalized 1
• SSRIs require weeks to achieve therapeutic effect and are intended for chronic, pervasive anxiety 1
• No functional impairment across multiple life domains 4

Alprazolam twice daily for social anxiety disorder:

• Wrong diagnosis – no evidence of pervasive social fears beyond this specific performance context 4
• Benzodiazepines are explicitly contraindicated in athletes due to marked hangover effects and negative impact on reaction time 1
• Chronic benzodiazepine use carries dependence risks inappropriate for a 17-year-old 1

Quetiapine at night for separation anxiety disorder:

• Completely wrong diagnosis – no separation concerns described 4
• Atypical antipsychotic inappropriate for performance anxiety 1
• Sedating effects would impair athletic performance 1

Clinical Approach

First-line intervention should be cognitive behavioral therapy (CBT), which is the optimal non-pharmacological intervention for anxiety in athletes 1. CBT can help the athlete:

• Reframe anxiety as facilitative rather than debilitating 6
• Develop coping strategies for high-pressure situations 3
• Address catastrophizing thoughts about recruiter presence 2

Propranolol as adjunctive pharmacotherapy when:

• CBT alone is insufficient or time-limited (recruiting season is immediate) 2
• Autonomic symptoms are severe enough to directly impair performance 2
• Dosed 30-60 minutes before anticipated high-stakes games 2

Important Caveats

• Screen for contraindications to beta-blockers (asthma, certain cardiac conditions, diabetes with hypoglycemia unawareness) 2
• Consider sport-specific regulations – some athletic organizations have restrictions on beta-blocker use 1
• Monitor for performance effects – while propranolol reduces peripheral anxiety symptoms, some athletes perform optimally at higher anxiety levels 6
• This is a bridge treatment – long-term goal should be psychological skill development to manage performance pressure without medication 1, 3

The key distinction is that this athlete has situational performance anxiety, not a chronic anxiety disorder requiring daily medication, making as-needed propranolol (when not contraindicated by sport regulations or medical conditions) the most appropriate pharmacological option alongside CBT. 1, 2