Question 1

Should I prescribe propranolol for my patient's public speaking anxiety?

Accepted Answer

Propranolol, a non-selective beta-1/beta-2 antagonist, is supported by robust evidence for performance anxiety—specifically, time-limited, situation-specific presentations (public speaking, performances, interviews). Its anxiolytic mechanism is entirely peripheral: it blocks the physical manifestations of anxiety (tachycardia, tremor, sweating) without affecting central worry, rumination, or apprehension. Classic crossover trials (Brantigan 1982, Brewer 1972) demonstrate efficacy for tremor and cardiovascular symptoms. Dosing: 10-40 mg (often 20 mg) taken 60-90 minutes before the event. NO evidence supports propranolol for GAD, panic disorder, or social anxiety disorder (general, non-performance contexts). A 2016 meta-analysis (Steenen) found no benefit for generalized anxiety. Propranolol is PRN only, not for daily use. CRITICAL SAFETY ISSUE: propranolol overdose is lethal due to severe bradycardia and cardiogenic shock. UK coroner reports document deaths from intentional propranolol overdose in young anxious patients. DO NOT prescribe to patients with depression, suicidality, or self-harm history. Contraindications: asthma (beta blockade of airways), bradycardia, decompensated heart failure, severe peripheral vascular disease, and depression with suicide risk. Propranolol should be restricted to PRN performance anxiety in emotionally stable patients with no access barriers to overdose.

Question 2

How does propranolol block peripheral symptoms without affecting cognitive anxiety?

Accepted Answer

Propranolol, a non-selective beta-1/beta-2 antagonist, is supported by robust evidence for performance anxiety—specifically, time-limited, situation-specific presentations (public speaking, performances, interviews). Its anxiolytic mechanism is entirely peripheral: it blocks the physical manifestations of anxiety (tachycardia, tremor, sweating) without affecting central worry, rumination, or apprehension. Classic crossover trials (Brantigan 1982, Brewer 1972) demonstrate efficacy for tremor and cardiovascular symptoms. Dosing: 10-40 mg (often 20 mg) taken 60-90 minutes before the event. NO evidence supports propranolol for GAD, panic disorder, or social anxiety disorder (general, non-performance contexts). A 2016 meta-analysis (Steenen) found no benefit for generalized anxiety. Propranolol is PRN only, not for daily use. CRITICAL SAFETY ISSUE: propranolol overdose is lethal due to severe bradycardia and cardiogenic shock. UK coroner reports document deaths from intentional propranolol overdose in young anxious patients. DO NOT prescribe to patients with depression, suicidality, or self-harm history. Contraindications: asthma (beta blockade of airways), bradycardia, decompensated heart failure, severe peripheral vascular disease, and depression with suicide risk. Propranolol should be restricted to PRN performance anxiety in emotionally stable patients with no access barriers to overdose.

Question 3

What dose and timing work for performance anxiety?

Accepted Answer

Propranolol, a non-selective beta-1/beta-2 antagonist, is supported by robust evidence for performance anxiety—specifically, time-limited, situation-specific presentations (public speaking, performances, interviews). Its anxiolytic mechanism is entirely peripheral: it blocks the physical manifestations of anxiety (tachycardia, tremor, sweating) without affecting central worry, rumination, or apprehension. Classic crossover trials (Brantigan 1982, Brewer 1972) demonstrate efficacy for tremor and cardiovascular symptoms. Dosing: 10-40 mg (often 20 mg) taken 60-90 minutes before the event. NO evidence supports propranolol for GAD, panic disorder, or social anxiety disorder (general, non-performance contexts). A 2016 meta-analysis (Steenen) found no benefit for generalized anxiety. Propranolol is PRN only, not for daily use. CRITICAL SAFETY ISSUE: propranolol overdose is lethal due to severe bradycardia and cardiogenic shock. UK coroner reports document deaths from intentional propranolol overdose in young anxious patients. DO NOT prescribe to patients with depression, suicidality, or self-harm history. Contraindications: asthma (beta blockade of airways), bradycardia, decompensated heart failure, severe peripheral vascular disease, and depression with suicide risk. Propranolol should be restricted to PRN performance anxiety in emotionally stable patients with no access barriers to overdose.

Question 4

Does propranolol work for generalized social anxiety or only performance situations?

Accepted Answer

Propranolol, a non-selective beta-1/beta-2 antagonist, is supported by robust evidence for performance anxiety—specifically, time-limited, situation-specific presentations (public speaking, performances, interviews). Its anxiolytic mechanism is entirely peripheral: it blocks the physical manifestations of anxiety (tachycardia, tremor, sweating) without affecting central worry, rumination, or apprehension. Classic crossover trials (Brantigan 1982, Brewer 1972) demonstrate efficacy for tremor and cardiovascular symptoms. Dosing: 10-40 mg (often 20 mg) taken 60-90 minutes before the event. NO evidence supports propranolol for GAD, panic disorder, or social anxiety disorder (general, non-performance contexts). A 2016 meta-analysis (Steenen) found no benefit for generalized anxiety. Propranolol is PRN only, not for daily use. CRITICAL SAFETY ISSUE: propranolol overdose is lethal due to severe bradycardia and cardiogenic shock. UK coroner reports document deaths from intentional propranolol overdose in young anxious patients. DO NOT prescribe to patients with depression, suicidality, or self-harm history. Contraindications: asthma (beta blockade of airways), bradycardia, decompensated heart failure, severe peripheral vascular disease, and depression with suicide risk. Propranolol should be restricted to PRN performance anxiety in emotionally stable patients with no access barriers to overdose.

PsychHQ

Propranolol for Performance Anxiety: Why It Works for Shaking Hands but Not Racing Thoughts