What is the recommended management for performance anxiety (stage fright)?

Management of Stage Fright (Performance Anxiety)

For performance anxiety (stage fright), cognitive behavioral therapy is the first-line treatment, with SSRIs (escitalopram or sertraline) reserved for patients who cannot access CBT, prefer medication, or have severe symptoms causing significant functional impairment. 1, 2

Initial Assessment and Severity Stratification

• Screen for symptom severity using validated anxiety measures (e.g., GAD-7) to determine whether the performance anxiety is limited to specific situations or represents generalized social anxiety disorder requiring chronic treatment 1
• Distinguish between occasional performance-limited anxiety (e.g., musicians, public speakers with infrequent events) versus chronic, recurrent performance anxiety causing significant distress or functional impairment across multiple situations 2
• Rule out medical causes including hyperthyroidism, caffeinism, hypoglycemia, cardiac arrhythmias, and other endocrine disorders before initiating treatment 2
• Assess for comorbid conditions, as approximately one-third of anxiety patients have co-occurring depression, substance use, or other psychiatric disorders 2

Treatment Algorithm Based on Severity and Frequency

For Occasional, Situational Performance Anxiety

• As-needed strategies may be sufficient when performance anxiety occurs only occasionally and does not cause significant functional impairment 2
• Beta-blockers (propranolol) have been used off-label for acute performance situations in musicians and public speakers, though this represents limited controlled evidence and Canadian guidelines deprecate beta-blockers for chronic social anxiety disorder treatment 2
• Important caveat: Beta-blockers are not recommended for generalized anxiety disorder or chronic social anxiety disorder due to lack of therapeutic benefit 2

For Chronic, Recurrent, or Functionally Impairing Performance Anxiety

Treat as chronic social anxiety disorder using the following stepped approach:

Step 1: First-Line Psychological Treatment (Preferred Initial Approach)

• Individual cognitive behavioral therapy (CBT) is the treatment with the highest level of evidence, showing small-to-moderate effect sizes versus placebo 1, 2
• Provide 12-20 CBT sessions over 3-4 months for significant symptomatic and functional improvement 1, 2
• CBT should include specific elements: education on anxiety, cognitive restructuring to challenge distortions, relaxation techniques (breathing exercises, progressive muscle relaxation), and gradual exposure to performance situations 1, 2
• Individual CBT is superior to group therapy in both clinical effectiveness and cost-effectiveness 1, 2
• If face-to-face CBT is unavailable or declined, self-help CBT programs with professional support are a viable alternative 1, 2

Step 2: First-Line Pharmacotherapy (When Indicated)

Offer pharmacologic treatment when:

• First-line psychological/behavioral treatments are inaccessible 1, 3
• Patient prefers medication after shared decision-making 1, 3
• Symptoms persist for more than 8 weeks despite adequate non-pharmacologic therapy 1, 2
• Functional impairment is substantial despite mild symptom scores 2

Preferred SSRI options:

• Escitalopram: Start 5-10 mg daily, increase by 5-10 mg increments every 1-2 weeks, target dose 10-20 mg/day 2

  • Lowest potential for drug-drug interactions and smallest discontinuation-symptom burden 2

• Sertraline: Start 25-50 mg daily, increase by 25-50 mg increments every 1-2 weeks, target dose 50-200 mg/day 2

  • Equally effective with favorable side effect profile 2

• Paroxetine and fluvoxamine: Reserve as second-tier options due to higher discontinuation symptoms and greater drug interaction potential 2

Expected timeline:

• Statistically significant improvement may begin by week 2 2
• Clinically significant improvement expected by week 6 2
• Maximal therapeutic benefit achieved by week 12 or later 2

Common side effects to monitor:

• Nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, dizziness, somnolence 1, 2
• Most adverse effects emerge within first few weeks and typically resolve with continued treatment 2
• Critical warning: Monitor for suicidal thinking and behavior, especially in first months and following dose adjustments (pooled risk 1% vs 0.2% placebo) 2

Step 3: Second-Line Pharmacotherapy

• Venlafaxine extended-release 75-225 mg/day is an effective alternative when first-line SSRIs fail after 8-12 weeks at therapeutic doses 1, 2
• Requires blood pressure monitoring due to risk of sustained hypertension 2
• Higher discontinuation-syndrome risk; taper gradually over 10-14 days when stopping 2

Step 4: Combined Treatment (Optimal for Moderate-to-Severe Cases)

• Combining SSRI/SNRI with individual CBT provides superior outcomes compared to either treatment alone for patients with moderate to severe performance anxiety 1, 2
• This combination is supported by moderate-to-high strength evidence 1, 2

Adjunctive Non-Pharmacological Strategies

• Structured physical activity and exercise provides moderate to large reduction in anxiety symptoms 1, 2
• Breathing techniques, progressive muscle relaxation, grounding strategies, and mindfulness are useful adjuncts to primary treatment 1, 2
• Avoid excessive caffeine and alcohol as both can exacerbate anxiety symptoms 2
• Sleep hygiene education to address insomnia which commonly co-occurs with anxiety 1, 2

Medications to Avoid

• Benzodiazepines should be limited to short-term (days to a few weeks) adjunctive use only due to high risk of dependence, tolerance, cognitive impairment, and withdrawal syndromes 1, 2
• Benzodiazepines must not be used as first-line or long-term therapy 1, 2
• Hydroxyzine (Vistaril) has LOW evidence quality with only WEAK strength of recommendation and cannot be recommended as a reliable first-line treatment 3

Treatment Duration and Monitoring

• Continue effective medication for a minimum of 9-12 months after achieving remission to prevent relapse 2
• Reassess monthly until symptoms stabilize, then every 3 months 2
• Monitor treatment adherence, side effects, and functional improvement using standardized scales 2
• If no improvement after 8 weeks at therapeutic doses despite good adherence, switch to different SSRI or add CBT 2

Critical Pitfalls to Avoid

• Do not commence pharmacotherapy before trialing evidence-based CBT, which provides more durable benefits 2
• Do not abandon treatment prematurely; full response may take 12+ weeks 2
• Do not escalate SSRI doses too quickly; allow 1-2 weeks between increases to assess tolerability 2
• Relying on medication alone is insufficient; integrating CBT with pharmacotherapy yields superior outcomes 2
• Patients with anxiety commonly avoid follow-through on referrals; proactively assess and address barriers to treatment adherence 2