In an otherwise healthy adult with occasional performance or test anxiety, should clonidine or propranolol be used, and what are the appropriate starting doses?

Propranolol for Performance Anxiety

For occasional performance or test anxiety in healthy adults, propranolol is the preferred agent over clonidine, starting at 10-40 mg taken 30-60 minutes before the anxiety-provoking event.

Why Propranolol Over Clonidine

Propranolol is the established choice for situational performance anxiety because it specifically targets the peripheral manifestations of anxiety (tremor, tachycardia, sweating) without the significant central nervous system effects and safety concerns associated with clonidine 1, 2.

Clonidine carries substantial risks that make it inappropriate for occasional use:

• Life-threatening rebound hypertensive crisis can occur within 24-36 hours of abrupt discontinuation, requiring a mandatory taper of 33% dose reduction every 2 days over at least 4-8 days 3
• Significant CNS adverse effects including sedation, drowsiness, and orthostatic hypotension 3, 4
• Reserved as a last-line agent due to these safety concerns 3, 4
• Requires continuous daily dosing rather than as-needed use 4

Propranolol Dosing for Performance Anxiety

Starting dose: 10-40 mg taken 30-60 minutes before the performance or test 1, 2

• This as-needed dosing strategy is ideal for occasional situational anxiety
• The beta-blocking effect reduces physical symptoms (tremor, palpitations, sweating) that often worsen performance anxiety
• Can be titrated based on response and tolerability

When Clonidine Might Be Considered (Not for Your Scenario)

Clonidine is only appropriate for chronic, treatment-resistant anxiety disorders requiring daily management 5:

• Starting dose: 0.05-0.1 mg at bedtime 4
• Gradual titration to 0.1 mg 2-3 times daily, maximum 0.4 mg per day 4
• Requires daily administration and cannot be stopped abruptly 3

Recent evidence suggests clonidine may have anxiolytic effects in treatment-resistant cases, but this remains investigational with inconsistent efficacy 5. Short-term anxiolytic effects do not persist with long-term administration in most patients 6.

Critical Safety Considerations

For propranolol:

• Contraindicated in asthma, severe bradycardia, or heart block 1
• May mask hypoglycemia symptoms in diabetics 1

For clonidine (if ever used):

• Never discontinue abruptly—requires mandatory taper 3
• Hold dose if heart rate <50 bpm or systolic BP <100 mmHg 3
• Monitor for orthostatic hypotension, especially in elderly 3
• Alternative antihypertensive agents must be started at the beginning of any taper, not after discontinuation 3