What is the preferred beta‑blocker and dosing for performance‑related anxiety in a healthy adult without asthma, COPD, severe bradycardia, high‑grade atrioventricular block, uncontrolled heart failure, or diabetes?

Propranolol for Performance-Related Anxiety

For performance-related anxiety in a healthy adult without contraindications, propranolol is the preferred beta-blocker, dosed at 10–40 mg taken 30–60 minutes before the anxiety-provoking event, with a maximum single dose of 40 mg. 1

Why Propranolol Is the Preferred Agent

• Propranolol is a non-selective beta-blocker that blocks peripheral adrenergic effects (tremor, palpitations, tachycardia, sweating) that underlie performance anxiety, making it uniquely effective for situational use. 2
• The American College of Cardiology and American Heart Association explicitly recognize propranolol as the evidence-based choice for performance anxiety and situational triggers with prominent somatic symptoms. 1
• Propranolol is effective in up to 70% of patients for tremor control and has established efficacy for reducing physiologic tremor during performance situations. 2

Dosing Strategy

• For infrequent performance situations (e.g., public speaking, musical performance, test-taking), use a single dose of 10–20 mg taken 30–60 minutes before the event; if inadequate, increase to 20–40 mg for subsequent events. 1
• The maximum single situational dose should not exceed 40 mg. 1
• If performance anxiety occurs frequently (multiple times per week), consider chronic daily dosing: start immediate-release propranolol 40 mg twice daily (total 80 mg/day) and titrate to 80–160 mg/day in two divided doses, or use long-acting propranolol 80 mg once daily, titrating to 120–160 mg once daily. 1
• For patients on chronic daily dosing who face a known high-stakes event, a supplemental 10–20 mg immediate-release dose may be added 30–60 minutes beforehand. 1

Mandatory Pre-Treatment Screening

Before prescribing propranolol, screen for absolute contraindications:

• Asthma, COPD, or any obstructive airway disease (non-selective beta-blockade can precipitate life-threatening bronchospasm). 1
• Second- or third-degree atrioventricular block (without a pacemaker). 1
• Decompensated heart failure or severe left ventricular dysfunction. 1
• Sinus bradycardia or sinus node dysfunction (without a pacemaker). 1
• Cardiogenic shock or severe hypotension. 1
• History of hypoglycemic episodes (propranolol masks adrenergic warning signs of low blood glucose). 1

Baseline assessment should include:

• Heart rate and blood pressure measurement. 1
• Cardiovascular examination with auscultation. 1
• Screening for history of bronchospasm, diabetes, and concurrent medications that affect cardiac conduction (especially non-dihydropyridine calcium-channel blockers such as diltiazem or verapamil). 1

Critical Safety Warnings

• Propranolol should be taken with food to reduce the risk of hypoglycemia, particularly in patients who have not eaten recently. 1
• In patients with diabetes or a history of hypoglycemia, propranolol masks typical adrenergic warning signs (tremor, rapid heartbeat, palpitations); counsel these patients to monitor blood glucose more frequently and rely on non-adrenergic cues (hunger, confusion, sweating) to detect low blood sugar. 1
• Avoid routine co-administration with non-dihydropyridine calcium-channel blockers (diltiazem, verapamil) because the combination markedly increases the risk of severe bradycardia and heart block. 1
• After regular propranolol use, abrupt discontinuation can trigger rebound hypertension, tachycardia, or angina; taper gradually over 1–3 weeks when discontinuing. 1

Monitoring for Excessive Beta-Blockade

Watch for signs of excessive beta-blockade, especially after the first dose or any dose increase:

• Dizziness, light-headedness, or marked fatigue. 1
• Heart rate falling below 50 beats per minute. 1
• Systolic blood pressure dropping below 90 mm Hg. 1
• New or worsening shortness of breath or wheezing. 1

Why Not Other Beta-Blockers?

• Atenolol is not recommended for performance anxiety because it is less effective for blood-pressure control, lacks proven benefit for situational anxiety, and has limited evidence for tremor reduction. 1, 2
• Metoprolol is a second-line alternative only for patients with asthma or reactive airway disease (because it is cardioselective), but it is significantly less effective than propranolol for tremor control and may not differ from placebo over long-term treatment. 2
• Beta-blockers with intrinsic sympathomimetic activity (acebutolol, pindolol) are ineffective for tremor and should be avoided. 2
• Nadolol is a non-selective alternative when once-daily dosing is required, but it lacks the extensive evidence base that propranolol has for performance anxiety. 3

When Propranolol Is Not Appropriate

• For chronic generalized anxiety disorder or panic disorder, propranolol is not first-line therapy; SSRIs or SNRIs are preferred. 2
• For frequent or chronic performance anxiety requiring daily treatment, consider cognitive behavioral therapy (CBT) as first-line, with SSRIs/SNRIs as pharmacotherapy if needed, rather than chronic beta-blocker use. 2
• The Japanese Society of Anxiety and Related Disorders deprecates propranolol for generalized social anxiety disorder based on negative evidence, but explicitly endorses it for performance anxiety and specific situational triggers with prominent somatic symptoms. 1

Common Pitfalls to Avoid

• Do not prescribe propranolol for the first time on the day of an important event; advise a trial dose before a lower-stakes situation to assess individual response and tolerability. 2
• Do not use propranolol in patients with predominantly psychological symptoms (worry, rumination) rather than physical symptoms (tremor, palpitations, sweating); it is ineffective for cognitive anxiety. 1
• Do not combine propranolol with diltiazem or verapamil; this combination is contraindicated due to the high risk of severe bradycardia and heart block. 1

Evidence Summary

The recommendation for propranolol as the preferred beta-blocker for performance anxiety is based on strong guideline evidence from the 2022 Hypertension individualized beta-blocker guidelines 4, the 2026 American College of Cardiology and American Heart Association guidance 1, and the 2026 practical summaries of clinical guidelines 2. A 2025 systematic review and meta-analysis found no evidence for beta-blockers in chronic anxiety disorders (social phobia, panic disorder) 5, but the guideline consensus explicitly distinguishes situational performance anxiety—where propranolol has established efficacy—from chronic anxiety disorders. 1, 2