Propranolol Dosing for Performance Anxiety
For performance anxiety, take propranolol 10-40 mg as a single dose 30-60 minutes before the anxiety-provoking event, and this can be used as needed for each separate performance or situational trigger without a maximum frequency limit, provided you do not have contraindications. 1, 2
Optimal Dosing Strategy
The most effective approach is situational use only—not daily dosing—with 10-20 mg taken 30-60 minutes before each triggering event. 1 This can be repeated for each separate performance or public speaking engagement without concern for frequency, as long as doses are separated by the duration of individual events. 2
- Higher doses up to 40 mg may be used for more severe somatic symptoms (tremor, palpitations, sweating), but most patients respond adequately to 10-20 mg. 1, 2
- The medication works specifically on physical/autonomic symptoms rather than psychological worry, making it ideal for performance situations where tremor and palpitations are the primary concern. 2, 3
Critical Pre-Use Safety Check
Before each dose, check your pulse—hold the dose if your heart rate is below 60 beats per minute. 2 This simple safety measure prevents excessive bradycardia with as-needed use.
Absolute Contraindications (Never Use If You Have):
- Asthma or reactive airway disease (can cause life-threatening bronchospasm) 1, 2
- Second or third-degree heart block 1, 2
- Decompensated heart failure or significant left ventricular dysfunction 1, 2
- Cardiogenic shock or severe hypotension 1, 2
- Sinus node dysfunction without a pacemaker 1, 2
Special Warnings:
- Diabetic patients: Propranolol masks hypoglycemia symptoms (shakiness, rapid heartbeat), making low blood sugar harder to recognize. 1, 2 Use with extreme caution and monitor glucose closely.
- Never combine with diltiazem or verapamil (non-dihydropyridine calcium channel blockers) due to excessive bradycardia and heart block risk. 4, 2
When Propranolol Works Best
Propranolol is most effective for situational/performance anxiety with prominent physical symptoms rather than chronic generalized anxiety. 2, 3 Ideal candidates experience:
- Tremor during presentations or performances 2, 3
- Palpitations and rapid heartbeat in social situations 2, 3
- Sweating and autonomic hyperactivity 2, 3
It is NOT recommended for chronic daily anxiety or generalized social anxiety disorder. 1 The Japanese Society of Anxiety and Related Disorders specifically deprecates propranolol for generalized social anxiety but endorses it for performance anxiety with somatic symptoms. 1
Monitoring for As-Needed Use
- No routine monitoring is required for occasional as-needed use in otherwise healthy patients. 2
- Watch for adverse effects including fatigue, dizziness, cold extremities, and excessive slowing of heart rate. 2
- If you develop wheezing or breathing difficulty, stop immediately and seek medical attention. 1
Evidence Supporting As-Needed Use
Research demonstrates that a single 40 mg dose of propranolol one hour before the SAT improved test scores by 130 points in students with test anxiety (p < 0.01), confirming objective benefit for situational cognitive performance under stress. 5 The therapeutic range for situational anxiety is consistently reported as 20-40 mg per dose, taken once to three times daily only when needed. 3
Important caveat: While propranolol effectively controls physical symptoms, cognitive-behavioral therapy shows superior outcomes for overall performance anxiety, including improved performance quality and confidence. 6 Consider combining approaches for optimal results.