Can a healthy adult without asthma, COPD, bradycardia, atrioventricular block, heart failure, peripheral vascular disease, or beta‑blocker allergy safely use propranolol for performance anxiety during public speaking, and what dose is appropriate?

Propranolol for Public Speaking Anxiety

A healthy adult without contraindications can safely use propranolol 10–40 mg taken 30–60 minutes before a public speaking event to control performance anxiety. 1

Patient Selection and Contraindications

Before prescribing propranolol for situational anxiety, you must exclude the following absolute contraindications:

• Obstructive airway disease (asthma, COPD) – non-selective β-blockade can precipitate life-threatening bronchospasm 1
• Second- or third-degree atrioventricular block without a pacemaker 1
• Decompensated heart failure or cardiogenic shock 1
• Sinus bradycardia or sinus node dysfunction without a pacemaker 1
• Systolic blood pressure <90 mmHg 1

Propranolol works best for patients whose anxiety manifests primarily as physical symptoms – tremor, palpitations, tachycardia, sweating, and other autonomic hyperactivity – rather than predominantly psychological symptoms like worry or rumination. 1

Recommended Dosing Protocol

For situational performance anxiety (public speaking, presentations):

• Single dose: 10–20 mg taken 30–60 minutes before the event 1
• Maximum single dose: 40 mg 1
• This is not suitable for chronic daily anxiety treatment – propranolol is specifically effective for performance anxiety and specific situational triggers with prominent somatic symptoms 1

The Japanese Society of Anxiety and Related Disorders explicitly deprecates propranolol for generalized social anxiety disorder based on negative evidence, but endorses it for performance anxiety with a maximum single dose of 40 mg. 1 This distinction is critical: propranolol excels at blocking the peripheral manifestations of acute stress (tremor, rapid heart rate) but does not address chronic psychological anxiety.

Pre-Treatment Assessment

Mandatory screening before first dose:

• Measure resting heart rate and blood pressure – hold if HR <60 bpm or systolic BP <100 mmHg 1
• Auscultate lungs for wheezing or evidence of obstructive airway disease 1
• Screen for history of bronchospasm, diabetes, and concurrent medications that affect cardiac conduction (diltiazem, verapamil, digoxin, amiodarone) 1
• Obtain cardiovascular examination with auscultation to detect murmurs or signs of heart failure 1

No routine laboratory work, ECG, or echocardiogram is required in otherwise healthy adults without cardiac concerns. 1 This makes propranolol particularly practical for situational use in low-risk patients.

Administration and Safety Considerations

Take propranolol with food to reduce the risk of hypoglycemia, especially if you have not eaten recently. 1 This is particularly important for patients with diabetes or any history of hypoglycemic episodes.

Watch for signs of excessive beta-blockade after administration:

• Dizziness, lightheadedness, or marked fatigue 1
• Heart rate falling below 50 bpm 1
• Systolic blood pressure dropping below 90 mmHg 1
• New or worsening shortness of breath or wheezing 1

For diabetic patients: Propranolol masks the typical adrenergic warning signs of hypoglycemia (tremor, rapid heartbeat, sweating). You must rely on non-adrenergic cues like hunger, confusion, or sweating to detect low blood glucose, and monitor glucose more frequently. 1

Critical Drug Interactions

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 If a patient is already taking these medications, propranolol is not appropriate for situational anxiety.

Discontinuation Guidance

If you use propranolol regularly (not just for occasional public speaking), never stop abruptly. Sudden discontinuation after chronic use can trigger rebound hypertension, tachycardia, or angina. Taper gradually over 1–3 weeks. 1 However, for truly situational use (one dose before a speech), this concern does not apply.

Evidence Quality and Clinical Context

The recommendation for propranolol in performance anxiety is supported by multiple guideline societies including the American Heart Association and American College of Cardiology. 1 Older research from the 1970s–1990s demonstrated that propranolol 20–40 mg effectively reduces rated anxiety in speakers' non-verbal behavior and self-reported anxiety, while also reducing pulse rate. 2 A 1976 long-term study of 513 patients found that 80–320 mg daily controlled somatic and psychic symptoms of anxiety, though these were chronic anxiety patients rather than situational users. 3

The key distinction: Propranolol is not effective for generalized anxiety disorder or panic disorder when used alone. 4 Its utility is restricted to patients with prominent physical symptoms who have not responded adequately to benzodiazepines, or for specific performance situations. 5

Common Pitfalls to Avoid

• Do not prescribe propranolol for chronic daily anxiety – it is specifically indicated for situational performance anxiety 1
• Do not exceed 40 mg as a single situational dose 1
• Do not use in patients with any history of wheezing or reactive airway disease – even a single dose can precipitate bronchospasm 1
• Do not combine with other rate-lowering medications without careful consideration of additive bradycardic effects 1