Which beta‑blocker and dosing regimen is recommended for an adult with performance‑related anxiety without contraindications, and what are the contraindications and alternative agents?

Beta-Blockers for Performance-Related Anxiety

Propranolol 10–40 mg taken 30–60 minutes before the anxiety-provoking event is the recommended beta-blocker for performance-related anxiety in adults without contraindications. 1, 2

Recommended Agent and Dosing

• Propranolol is the only beta-blocker with evidence for situational/performance anxiety, working by blocking peripheral adrenaline effects to reduce rapid heart rate, tremors, and sweating. 2, 3
• Start with 10–20 mg as a trial dose before any important event to assess individual response and tolerability, then use 20–40 mg for subsequent performances. 1, 2
• Timing is critical: administer 30–60 minutes (ideally 1 hour) before the performance to achieve peak effect. 1, 2
• Propranolol is specifically effective for anxiety with prominent somatic/physical symptoms (tremor, palpitations, tachycardia, sweating) rather than psychological worry. 1, 2

Why Propranolol Over Other Beta-Blockers

• Propranolol is non-selective, blocking both β1 and β2 receptors, which provides superior control of peripheral autonomic symptoms compared to cardioselective agents. 2, 3
• Atenolol and other cardioselective beta-blockers are explicitly NOT recommended for anxiety—Canadian and international guidelines (2023) deprecate both atenolol and propranolol for chronic social anxiety disorder based on negative evidence. 2
• Metoprolol has inferior efficacy for tremor and anxiety compared to propranolol and should only be considered if propranolol is contraindicated. 3

Absolute Contraindications (Must Screen Before Prescribing)

Do not prescribe propranolol if the patient has any of the following:

• Asthma, chronic obstructive pulmonary disease, or any obstructive airway disease (non-selective β-blockade can precipitate life-threatening bronchospasm). 4, 1, 2
• Second- or third-degree heart block or sinus node dysfunction without a pacemaker (risk of profound bradycardia and heart block). 1, 2
• Decompensated heart failure or significant left ventricular dysfunction (beta-blockade can worsen cardiac output). 1, 2
• Cardiogenic shock or severe hypotension (systolic BP <90 mmHg). 1, 2
• Known hypersensitivity to propranolol. 2

Mandatory Pre-Treatment Assessment

Before prescribing propranolol, perform the following screening:

• Measure baseline heart rate and blood pressure (hold if HR <50 bpm or systolic BP <90 mmHg). 1
• Auscultate lungs for wheezing or evidence of reactive airway disease. 1, 3
• Perform cardiovascular examination with auscultation to detect murmurs, irregular rhythm, or signs of heart failure. 1
• Screen for history of bronchospasm, diabetes, and concurrent medications that affect cardiac conduction (especially non-dihydropyridine calcium channel blockers like diltiazem or verapamil). 4, 1

When Additional Testing Is Needed

• ECG and echocardiogram are only required in patients with suspected cardiac abnormalities, abnormal cardiac examination, or family history of congenital heart disease. 1
• Routine blood work (CBC, renal, liver, thyroid function) is NOT required in otherwise healthy adults before starting propranolol. 1

Special Populations and Cautions

Diabetes

• Propranolol masks adrenergic hypoglycemia symptoms (tremor, tachycardia, palpitations), potentially delaying recognition of low blood glucose. 1, 2, 3
• Counsel diabetic patients to increase blood glucose monitoring frequency and rely on non-adrenergic warning signs (sweating, hunger, confusion). 1, 3
• Administer propranolol with food to reduce hypoglycemia risk. 1

Elderly Patients

• Lower doses may be required due to altered pharmacokinetics and increased sensitivity to beta-blockade. 1
• Monitor closely for orthostatic hypotension, dizziness, and falls. 1

Critical Safety Warnings

Signs of Excessive Beta-Blockade (Instruct Patient to Stop and Seek Care)

• Dizziness, light-headedness, or marked fatigue 1
• Heart rate falling below 50 beats/min 1
• Systolic blood pressure dropping below 90 mmHg 1
• New or worsening shortness of breath or wheezing 1

Discontinuation

• Never abruptly discontinue propranolol after regular use (more than a few weeks of daily dosing), as this can precipitate rebound hypertension, tachycardia, or angina. 4, 1, 2
• Taper gradually over 1–3 weeks if discontinuation is necessary. 1

Drug Interactions

• Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of severe bradycardia and heart block. 4, 1

When Beta-Blockers Are NOT Appropriate

Beta-blockers are explicitly NOT recommended for chronic anxiety disorders:

• Canadian and international guidelines (2023) deprecate propranolol for generalized social anxiety disorder and panic disorder based on negative evidence from controlled trials. 2, 5
• A 2025 systematic review and meta-analysis found no evidence for beneficial effect of beta-blockers compared with placebo or benzodiazepines in patients with social phobia or panic disorder (p ≥0.54 for all comparisons). 5
• Older studies from the 1980s–1990s showed conflicting results, with propranolol possibly useful only for anxiety with prominent physical symptoms when combined with benzodiazepines. 6, 7, 8, 9

Alternative Agents for Chronic Anxiety

If the patient has frequent or chronic anxiety (not just situational performance anxiety):

• First-line treatment is cognitive behavioral therapy (CBT), which shows superior long-term outcomes. 2
• First-line pharmacotherapy is SSRIs (escitalopram, sertraline) or SNRIs (venlafaxine), NOT beta-blockers. 2
• Reserve propranolol only for acute situational use in patients with chronic anxiety who also need symptom control before specific performances. 2

Practical Clinical Algorithm

1. Determine anxiety pattern:

   • Situational/performance-only (public speaking, auditions, presentations) → Consider propranolol 2
   • Frequent or chronic anxiety → Refer for CBT and/or initiate SSRI/SNRI 2

2. Screen for absolute contraindications (asthma, heart block, heart failure, severe hypotension, cardiogenic shock). 1, 2

3. Perform baseline assessment (heart rate, blood pressure, lung auscultation, cardiac examination). 1

4. Prescribe propranolol 10–20 mg as a trial dose before a low-stakes event to assess response. 1, 2

5. If tolerated, prescribe 20–40 mg to take 1 hour before future performances. 1, 2

6. Counsel on warning signs of excessive beta-blockade and when to hold the dose. 1

7. Do NOT prescribe for daily use unless treating a different indication (hypertension, essential tremor). 2

Common Pitfalls to Avoid

• Do not prescribe propranolol for chronic daily anxiety—it is ineffective and not guideline-recommended. 2, 5
• Do not assume all beta-blockers are equivalent—only propranolol has evidence for performance anxiety. 2, 3
• Do not skip the trial dose—individual response varies, and you want to avoid a first-time adverse reaction during an important performance. 1, 2
• Do not combine with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to severe bradycardia risk. 4, 1
• Do not prescribe in patients with any history of wheezing or reactive airways—even mild asthma is an absolute contraindication. 1, 2