musician with performance anxiety propranolol

Propranolol for Anxiety: A Complete Guide to Its History, Benefits, Side Effects, & Risks

This post has been reviewed by our Medical Review Board of U.S. Physicians. Propranolol is not FDA approved for the treatment of anxiety, however it has been safely prescribed for the treatment of performance anxiety for decades as an “off label” use at the sole discretion of a licensed physician.

Experience intense anxiety, shakes, and sweating before engaging in a high stress task like public speaking, taking an exam, or performing in front of an audience? While many people feel some level of anxiousness before these events, those with severe anxiety that is impacting their lives, performance, and livelihoods sometimes turn to medicine for help in managing their symptoms.

Sometimes if left untreated, these debilitating attacks of anxiety can cause individuals to avoid and withdraw from stressful and social situations which can have a severe long term negative impact on a person’s quality of life.

There are a few classes of drugs that are commonly prescribed for the treatment of anxiety including benzodiazepines (like Xanax), SSRI’s (like Lexapro), and beta blockers (like Propranolol). However for situational performance anxiety benzos may negatively impact performance and long term use can lead to serious physical addictions and withdrawals, SSRI’s are typically a longer term solution and can take many months to show effect, which leaves beta blockers as a popular option as they can have a near immediate effect at reducing anxiety symptoms by controlling your body’s adrenaline “fight or flight” response without impacting physical or mental performance or the risk of developing a dependance.

Table of Contents

What is Propranolol?

Propranolol is a non-selective beta blocker that is FDA approved to treat high blood pressure, chest pain, uneven heartbeat, tremors, and migraine headaches. It was developed in 1962 and is one of the oldest and most widely used beta blockers on the market today with more than 16 million prescriptions for the medication in the US alone. It is sometimes prescribed for the “off label” use of performance and situational anxiety as it can block your body’s “fight or flight” response and allow your body to remain calm under stress.

What is Situational Performance Anxiety?

Situational or performance anxiety is defined by experiencing an overwhelming level of stress in response to a specific situation. Examples of common situations where people experience debilitating levels of performance anxiety include:

  • Going to a high stakes job interview
  • Crowded professional networking events
  • Long distance flights
  • Meeting up with someone new for a first date
  • Public speaking
  • Voicing an unpopular opinion in a meeting
  • Public debates
  • Playing a musical instrument in front of a crowd
  • During competitive sporting events such as pistol shooting, archery, billiards, and golf (note: Propranolol is labeled as a performance enhancing drug and banned in the Olympics and by the World Anti Doping Agency)

It’s important to understand the type of anxiety that you experience and that situational or performance anxiety is very different from something like Generalized-Anxiety-Disorder where people feel unrelenting levels of anxiety at all times rather than just before high stress situations. Understanding the type of anxiety you are suffering from is a critical first step when determining actions you can take to improve your symptoms.

Physical Symptoms of Performance Anxiety

While many people think of anxiety of as purely mental health condition, performance anxiety manifests itself through very physical symptoms which can impede performance and lessen your quality of life.

When you find yourself in a situation that your brain perceives as stressful, your body will go into “fight or flight” mode do to a release of hormones like epinephrine (also know as adrenaline). This is a valuable human response designed to keep you alive and aware of looming threats, however it becomes a problem when your body recognizes non life-threatening situations like public speaking as a life or death event that requires “fight or flight” hormones.

Examples of common physical symptoms people feel when experiencing performance anxiety include:

  • Nervousness
  • Irritability
  • Tiredness
  • Self Doubt
  • Tremors and Shaking Hands
  • Headaches
  • Sweating
  • Increased heartbeat
  • Blushing
  • Lightheadedness
  • Unable to Think Clearly

Mental Effects of Performance Anxiety and Negative Feedback Loops

While the physical symptoms of situational anxiety can impede your performance and become unbearable at times, the mental strain and your thought patterns around anxiety can be even worse.

Once you recognize that you get nervous before an event or situation, you will begin to dread the event and the associated negative feelings. Many people experience anxiety about the idea of getting anxious before an event and it becomes a negative self fulfilling feedback loop that they become stuck in. This can lead to avoidance behaviors of events and situations that could benefit you personally or professionally.

One of the most powerful effects beta blockers can have on those facing performance anxiety is allowing them to face stressful situations without the physical side effects which can improve their comfort and confidence when facing difficult situations in the future and break the negative feedback loop of anxiety.

Where Does Performance Anxiety Come From

There is much debate about where performance anxieties and phobias come from. It is likely not a singular factor that applies to all anxiety suffers, but instead a combination of personal and environmental factors that vary from person to person. My often doctors believe anxiety to stem from a combination of factors including:

  • Previous bad experiences or trauma
  • Lifestyle and diet choices
  • Personality times
  • Family history and genetic predisposition
  • Drug or supplement use
  • Underlying medical issues

While determining the exact cause for your anxiety is not vital, recognizing that you have a problem with anxiety is an important milestone in your path to choosing from treatment options and overcoming hurdles. One of the largest problems is when those who suffer from anxiety ignore their struggles which allows the problem to compound and the negative feedback loop to continue.

How Does Propranolol Help with Performance Anxiety

Propranolol and other beta blockers work by targeting beta receptors in your heart and other areas to effectively block or blunt your body’s “fight or fight” response triggered by adrenaline which can cause severe anxiety and physical symptoms like tremors, sweating, shaking, and rapid heart rate.

While propranolol will not address the root psychological issue of anxiety, studies show that propranolol can provide short term relief for many of the physical symptoms of anxiety and allow you to feel more comfortable in uncomfortable and stressful situations. By experiencing calmness during stressful situations, many people can reduce the self doubt they feel related to performing a specific task in the future which will reduce the initial level of anxiety symptoms they feel before the event and break the negative feedback loop of situational anxiety.

History of Propranolol and Beta Blocker Usage for Anxiety

Drug Discovery & History

Propranolol was first discovered and patented in 1962 by British scientist James W Black who later received a Nobel Prize for this historical discovery in 1988. Shortly after its discovery in 1965 its anti-anxiety effects were noted in a study related to the ability of propranolol to to reduce tachycardia (rapid heart rate). This sparked great interest in the drug from the psychiatric community who experimented with using propranolol for high trait anxiety in 1969, substance abuse disorder (heroin) in 1972, schizophrenia in 1974, autism in 1987, and aggressive behavior in 2006 with varying degrees of success, conclusiveness, and test population sample sizes.

In addition to these applications to serious disorders and mental illnesses, there are numerous studies and reports referencing successfully using propranolol to treat short term performance and event driven anxiety issues.

The Cure for Stage Fright? Propranolol Usage By Musicians

In 1979 the first mainstream article surfaced suggesting the use of propranolol for stage fright was published. This peaked the interest of performers around the world and in 1982 a small sample sized study showed increased ability of musicians to perform in front of large crowds when using propranolol. In the same year an article titled “A Cure for Stage Fright?” was published by a distinguished member of the Chicago Symphony which sparked additional interest among the classical music community.

This brought additional attention to widespread beta blocker use by classical musicians and further increased the popularity of usage. Following this attention came a slew of reports in regards the ethics of usage in classical music as it is perceived by some to be unfair in audition scenarios as it can give those who take it an unfair advantage over their competition when facing stage fright and performance anxiety. Despite the stigma, it continued to grow in popularity amongst musicians with studies referencing its frequent usage and a principal oboist in a major orchestra commenting on public radio in 2006 that “If you were to do some kind of drug test, I would imagine that at least 90 percent of them are [using beta blockers for performance anxiety].”

The discussion and frequent usage of beta blockers by classical musicians continues today as highlighted by a recent documentary titled Composed, which portrayed a deep dive into performance anxiety and conducted a Musician’s Health Survey in 2015 that found beta blockers to be the most effective tool for performance anxiety and found that 72% of musicians have reported to have tried them at least once.

Beta Blocker Usage in Golf for Performance Anxiety

Propranolol and beta blocker usage in golf was brought to public attention in 1994 when ex pro golfer Mac O’Grady claimed in an interview that at least 7 of the best golfers in the world have been using them and called for more strict drug testing. Australian pro golfer Craig Perry echoed these concerns in 2000 when he also claimed in an interview that many top pros where using beta blockers in order to improve performance.

Famous golfer Greg Norman made a similar statement that “In my day, a lot of guys were on beta blockers” and in 2008 the PGA, following the lead of WADA and the olympics, added beta blockers to the banned substance list. While there have be few public cases of pros testing positive for its use in recent years, beta blockers, like propranolol, continue to be popular among recreational golfers looking to steady their hands and improve their game.

Propranolol Usage for Test Anxiety

Another documented use case for beta blockers and propranolol in particular is the usage before exams to reduce test anxiety and potentially improve exam scores and performance. In 1980’s there were studies and articles about how propranolol could improve SAT performance among students who struggled with temporary memory recall issues due to performance anxiety during exams. There was a study that showed a marked improvement with a small sample size of students.

There have been multiple additional studies on the topic and the consensus between them is that those with anxiety disorders that result in them struggling with memory during testing situations due to stress see the most benefit and improvement in results when taking beta blockers. Students who don’t suffer from extreme anxiety are unlikely to see improvement in their results when taking beta blockers before testing. Students taking beta blockers to improve testing performance continues today with a recent study in 2018 among medical and dental students in Saudi Arabia showing more than 30% reported to using propranolol for testing purposes, many of these were self prescribed and students understood the risks of the drugs and how they worked to reduce symptoms of nervousness.

Propranolol Usage for PTSD

In recent years, some physicians have begun experimenting with using propranolol to treat lasting cases of PTSD and acute phobias by exposing them to their fears while taking propranolol to decouple their traumatic memories and experiences with their intense fear reactions and emotional memory (there is even a TV show based on this practice – A Cure for Fear). Numerous recent studies show promise for this use case, but it is not yet commonly accepted in the medical community.

Beta Blocker Usage by Surgeons

Surgeons who need steady hands and focus during stressful surgeries have also been known to use propranolol during medical operations. Studies have shown that propranolol successfully reduced surgeon’s anxiety and hand tremors during surgery in a safe and effective manner which may be able to improve patient outcomes and reduce mistakes.

Beta Blocker Usage by Patients in Surgery Preparation

Propranolol is not only used by surgeons, but also patients who suffer severe anxiety around invasive medical procedures. There have been instances that showed propranolol reduced patients fear of undergoing surgery with little risk or side effects. It’s important to talk to your doctor or surgeon before deciding to take propranolol pre-surgery to ensure it doesn’t increase the risk of complications or negatively effect the healing process.

How to Get Propranolol for Anxiety

Talk to your doctor about your symptoms and see if propranolol is a good fit for you. If your primary care physician is unsure whether it is appropriate, many psychiatrists are very open to using propranolol for anxieties so that could be another viable option to pursue. If you would prefer to not schedule an in-person appointment, offers online consultations with U.S. board certified physicians who can issue prescriptions for propranolol when appropriate and have the fulfilled medication shipped discreetly to your home.

Medical Community’s View of Off Label Propranolol Prescriptions

While many doctors view propranolol as a safe and effective treatment option for performance anxiety that has been used successfully for decades. Some feel as though there are better options available and it fails to address the underlying root cause of the patients anxiety, and thus is a poor long term solution to the problem. We recommend talking to a doctor to see if propranolol is right for your specific situation.

Propranolol Dosage for Anxiety

The usual dose for heart or high blood pressure related treatments is 80mg – 240mg per day for adults.

The typical dosage doctors recommend when prescribing propranolol for anxiety is much lower, typically 10mg-40mg taken on an as needed basis about an hour before high pressure situations or events. It’s typically recommended to start with a small dose of 10mg or 20mg to see how you feel and do a “trial” run with the medication rather than trying it for the first time on the day of an important event.

How Long Does Propranolol Last When Taken For Performance Anxiety

Propranolol has a half life of 8 to 10 hours, however the effects of the drug (duration of action) is slightly longer at around 12 hours. This time window gives an adequate time frame to suppress symptoms of anxiety during most stressful situations.

For propranolol most doctors recommend taking a low dose of 10mg – 20mg roughly an hour before the stressful event and then gradually increase the dose if needed for effectiveness.

Propranolol Interactions, Risk Factors, and Possible Side Effects

Propranolol is a prescription medication with the potential for serious side effects, and its usage should not be taken lightly. Before taking propranolol it’s important to talk to your doctor if you have a history of:

  • Asthma, bronchospasm, or other problems related to breathing
  • Cardiogenic shock
  • Slower than normal heart rate
  • Raynaud’s syndrome or other peripheral artery diseases
  • Diabetes
  • Abnormal blood pressure levels

You should also notify your doctor of any medications you’re currently on to avoid any negative interactions.

Make sure to consult a certified medical professional to ensure propranolol is a safe treatment option for you and make sure you are receiving your medication from a certified US pharmacy to insure accurate dosing and quality standards are met.

It’s also important to point out that, although that there are potential side effects you could encounter if you decide to use propranolol including:

  • Slowed heart rate
  • Hair loss
  • Dry eyes
  • Nausea
  • Weakness or fatigue
  • Breathing problems
  • Changes in blood pressure
  • Vomiting

Although rare, more serious side efforts from propranolol can also occur. If you experience any of the following side effects after taking propranolol contact your doctor as soon as possible for assistance.

  • Significantly Reduced Heart Rate
  • Low Blood Sugar
  • Cold hands or feet
  • Rapid weight gain or fluid retention
  • Severe nausea, diarrhea, or vomiting
  • Shortness of breath
  • Visual Hallucinations
  • Dizziness, light-headedness, or loss of consciousness

Stigma of Using Propranolol for Performance Anxiety

While many physicians and psychiatrists are increasing willing to prescribe propranolol off label for performance anxiety, there is some controversy around the ethics of the drug’s use especially in competitive situations like auditions, standardized test, and job interviews where individuals who take beta blockers may have a competitive advantage over those who don’t.

In some competitions like golf and the olympics where the substances are explicitly banned it is a clear cut issue of breaking the rules, but in other areas like standardized testing, recreational sports, and classical music auditions the answer is much less grey. In the end it comes do to an individuals own judgement to whether or not taking beta blockers to potential reduce symptoms of anxiety and improve performance in competitive situations is moral.

Beta Blockers vs Benzodiazepines for the Treatment of Performance Anxiety

Benzodiazepines such as Xanax and Valium are commonly prescribed to treat various forms of anxiety and phobias. At first glance beta blockers may seem similar to these benzo medications however they actually differ significantly in the following ways:

Propranolol Has Little Potential for Physical Addiction

Although effective at reducing anxiety, benzos can be extremely habit forming and can quickly create significant physical addiction and dependance that can lead to serious withdrawals and more deadly outcomes. While propranolol and other beta blockers can be misused and abused, they are not narcotic and not physically addictive so there is much less risk of physical dependance. Also ,many benzos are controlled substances due to their high abuse potential and propranolol is unscheduled and not controlled due to its more benign nature and low risk of abuse.

Propranolol is Best Used to Treat Short Term Event Driven Anxiety Issues

Often times benzos are prescribed for treatment of long term generalized anxiety disorders on an ongoing basis, beta blockers like propranolol are used to treat short term situational anxiety on a temporary or as needed basis.

Propranolol Effects How Adrenaline Impacts Your Body, Benzos Effect Your Brain

Benzos target parts of your brain and central nervous system to reduce anxiety, propranolol does not effect your brain directly, but instead it blocks the effect of adrenaline on your body. So in short, benzos attack the psychological aspect of anxiety whereas beta blocks simply reduce the physical symptoms that occurs when someone experiences anxiety.

Beta Blockers vs SSRI’s for the Treatment of Performance Anxiety

Originally used for depression, SSRI’s are a popular option that is being increasingly prescribed for various types of anxiety, phobia, and OCD. They are typically long term treatment and have shown effectiveness at helping with general anxiety disorders and other lasting mood disorders.

Beta Blockers are Much Faster Acting Than SSRI’s

Generally it can take 4 to 6 weeks to begin to notice benefits after you begin regularly taking SSRI’s. The full range of benefits can take upwards of 2 weeks to become apparent. During the initial days and weeks of beginning an SSRI regimen depression and anxiety symptoms can even worsen before positive effects are felt a few weeks in. Beta blockers on the other hand work within 30 – 60 minutes to ease symptoms of nervousness and anxiety without a worsening of side effects. However, beta blocker effects can be short lived compared to SSRI’s. Typically the relief from anxiety symptoms will last 12 hours after the initial dose, whereas SSRI’s can provide lasting improvement in mood and anxiety if taken regularly for many months.

Beta Blockers are Better Suited for Event Driven Situational Anxiety and SSRI’s Work for Long Term Anxiety & Depression

SSRI’s are typically prescribed on an ongoing basis for treatment of lasting conditions like depression, general anxiety disorder, and OCD. Propranolol is most successful used as a short term solutions for individuals suffering from event driven anxiety rather than an unrelenting level of stress despite the situation.

Beta Blockers and SSRI’s Have Very Different Mechanisms of Action

Beta blockers, like propranolol, work by blocking beta receptors in your body which can blunt the effect of the hormone adrenaline and prevent the physical manifestation of anxiety symptoms including rapid hear beat, shaky hands, tremors, sweaty palms, mind blanking, and more. SSRI’s on the other hand regulate the amount of serotonin in your brain and prevent rapid mood changes and feelings of depression and anxiety.

Differences in Side Effects Between Beta Blockers and SSRI’s

The side effect profile of both drugs is relatively moderate. Common side effects of SSRI’s include nausea, vomiting, dry month, increased anxiety, erectile dysfunction, insomnia, weight gain or loss, among others. The side effects of beta blockers include slowed heart rate, cold hands or feet, insomnia, and others. So while their risks profiles are generally comparable SSRI’s tend to him the potential for causing longer term issues due to their direct impact on brain function.

High Performing Individuals Who Have Reported to Use Propranolol for Performance Anxiety

With propranolol’s long history of off label use for anxiety treatments and as mental health has become a more focal point of society today, notable individuals have come out and talked out about their propranolol usage and their individual experiences with it.

Notable examples include:

Jim Safka – Former and CEO

Jim Safka is reported to use propranolol to become more confident when voicing his opinion in business meetings and public speaking in front of large crowds. He is reported to have said “I honestly believe it changed my life” when asked about propranolol, but noted that he rarely uses it today and just keeps it on hand in case of particularly stressful situations. Source

Katy Perry – American singer-songwriter

Katy Perry is reported to take beta blockers before performances due to intense nervousness and performance anxiety. Source

Shawn Mendes – Canadian singer-songwriter

Shawn Mendes reported to use beta blockers to “be less stressed out and calm down and breathe” when he performs. Source

Blair Tindall – American musician, performer

Blair Tindall reported to use Inderal (propranolol branded variation) on numerous occasions before performing to help with stage fright. Source

Kim Jong Su – North Korean olympic pistol shooting medalist

Kim Jong Su reportedly tested positive for propranolol usage during the 2008 Beijing Olympics and was disqualified and stripped of his silver and bronze medals. Propranolol is banned in olympic events due to its ability to reduce tremors and symptoms of anxiety in events that require steady hands and focus. Source

Conclusion: Not A Magic Pill, But a Valuable Tool to Have When Needed

Propranolol can be a great, low risk medication for individuals suffering from situational or performance anxiety, however it is not a “magic pill” cure all for anxiety suffers. While propranolol can have great effects on reducing symptoms of anxiety, without attempts to overcome the core psychological cause of the anxiety there will be little lasting effect. People who use propranolol as a tool to face stressful situations when needed along with proper training, visualization, practice, and exposure therapies tend to see the best lasting results in terms of overcoming performance anxiety in the long run.

Now you have an understanding of how propranolol can be used for anxiety, the potential risks of the medication, and the potential results you can expect from its usage. If you think propranolol is something that could benefit you, can connect you with a U.S. licensed physician who can help with determining if it’s the right fit for you and providing you with medication shipped from a U.S. licensed pharmacy directly to your home if approved.

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