Treatment for Stage Fright in Otherwise Healthy Adults
Propranolol 10-40 mg taken 1 hour before the performance is the treatment of choice for isolated stage fright in individuals without underlying anxiety or depression. 1, 2, 3
Why Propranolol is Optimal for Stage Fright
Propranolol works specifically by blocking peripheral beta-adrenergic receptors, preventing the physical manifestations of performance anxiety—tremor, palpitations, and tachycardia—without affecting cognitive function. 4, 3 This is fundamentally different from treating generalized anxiety disorder, where SSRIs would be first-line. 5
Key Evidence Supporting Propranolol
Propranolol 40 mg taken 1 hour before performance improved SAT scores by 130 points in students with test anxiety, demonstrating objective cognitive benefit. 2
In musicians, atenolol 100 mg (a beta-blocker) improved technical-motor performance and reduced heart rate during performance, with benefits occurring through peripheral action only. 4
Beta-blockers are effective when somatic/autonomic symptoms are prominent but not extreme, making them ideal for performance anxiety rather than panic attacks. 3
Improvement occurs within 1-2 hours at relatively low doses (propranolol 40 mg), which aligns perfectly with situational use before performances. 3
Dosing Strategy
Start with propranolol 10-20 mg taken 1 hour before the performance for initial trial. 3
If inadequate response, increase to 40 mg for subsequent performances. 2, 3
The medication can be used on an as-needed basis only before performances—no daily dosing required. 3
Why NOT to Use Anxiety Disorder Medications
SSRIs and SNRIs require 6-12 weeks for therapeutic effect and are designed for chronic anxiety disorders, not situational performance anxiety. 5 The evidence for SSRIs specifically addresses generalized anxiety disorder, social anxiety disorder, and panic disorder—conditions requiring at least 6 months of persistent symptoms for diagnosis. 5 Stage fright in an otherwise healthy individual is a circumscribed, situational response that does not meet criteria for these disorders. 6
Benzodiazepines should be avoided due to risks of cognitive impairment, dependence, and tolerance, and are only recommended for short-term use in true anxiety disorders. 5
Critical Caveats
Propranolol is contraindicated in asthma, severe bradycardia, heart block, and uncontrolled heart failure—screen for these conditions first. 1
This is considered off-label use in most countries, though it has decades of clinical experience supporting its efficacy. 1
If stage fright is severe, persistent across multiple situations, or accompanied by avoidance behaviors that impair daily functioning, this may actually represent social anxiety disorder requiring different treatment with SSRIs and/or CBT. 5
Propranolol does not reduce anticipatory anxiety before the performance begins, only the physical symptoms during performance. 4
When to Reconsider the Diagnosis
If the patient experiences anxiety in multiple social or performance situations beyond stage performance, has symptoms lasting more than 6 months, or demonstrates functional impairment in daily life, they may have social anxiety disorder rather than isolated stage fright and would benefit from SSRIs (escitalopram or sertraline) combined with individual CBT. 5