All About Propranolol for Performance Anxiety

Feeling anxious before a speech, event or social engagement? Originally designed to treat heart conditions, propranolol is also a highly effective medication prescribed off-label for treating the physical symptoms of social and performance anxiety.

Below, we’ve explained what propranolol is, how it works and how you can use it to manage most performance anxiety symptoms. We’ve also explained how propranolol differs from the other drugs used to treat anxiety, such as alprazolam (brand name Xanax) and diazepam (Valium).

Propranolol, (a.k.a. propranolol hydrochloride) is a beta blocker -- a type of medication that works by blocking the beta receptors found in your body, according to an article published in the book, StatPearls.

Developed in the 1960s, propranolol is one of the oldest and most widely used beta blockers in existence according to an article published in the Journal of Psychopharmacology. There are millions of prescriptions for propranolol in the US alone, making it an incredibly popular medication. It is sometimes sold under the brand name Inderal.

Propranolol is available in a variety of forms, from a release capsule to an injection. The majority of people who use propranolol on a regular basis are prescribed the oral version of the medication.

Like other beta blockers, propranolol was originally designed as a treatment for cardiovascular conditions, such as irregular heart rate (arrhythmias), increased heart rate (tachycardia) or high blood pressure. Most people who are prescribed propranolol use it for this purpose, according to the same StatPearls article.

It’s also commonly prescribed for off-label use to treat performance anxiety and social anxiety. 

How Long Does it Take For Propranolol to Work?

It will take about 30 to 60 minutes for you to notice the effects of propranolol. Those using propranolol for anxiety should plan to take their dose an hour or so before they wish to feel the desired effect. 

How Long Does Propranolol Stay in Your System?

Propranolol can stay in your system for about 1-2 days. However, the effects of the drug, if taken regularly, can last for up to a week.

First off, it’s important to understand that propranolol technically isn’t an anti-anxiety medication like Xanax (alprazolam, a benzodiazepine) or Zoloft (sertraline, an SSRI).

These drugs work by targeting specific parts of your brain and central nervous system, causing you to feel relaxed and calm. Although the specifics are complicated, they essentially work by stopping you from feeling the physical and psychological effects of anxiety.

Medications like Xanax and Zoloft usually treat long-term, persistent anxiety disorders such as panic disorder and generalized anxiety disorder (GAD). While Zoloft is needed on a daily basis to see results, Xanax, like propranolol, is taken on an as-needed basis for performance anxiety symptoms.

On the other hand, propranolol works by specifically targeting receptors in your body to block the action of stress hormones that cause the physical effects of anxiety.

It’s prescribed off-label as a treatment for specific types of anxiety that occur in certain situations, such as social anxiety or performance anxiety, according to the same article published in the Journal of Pharmapsychology.

Social anxiety usually occurs when you’re around other people. Many people feel anxiety about being judged by others or by doing or saying something embarrassing in a social environment.

Performance anxiety is a type of anxiety that can occur when you’re required to perform in front of others. You may have also heard it called “stage fright.”

It can strike when you need to perform in public, such as public speaking, as well as in private, such as having an interview one on one with someone.

When you feel anxiety, such as before meeting a new person or performing in front of others, it can trigger certain physical symptoms. According to an article published in the journal, Fronteirs in Psychology, these physical symptoms of anxiety include:

• A dry mouth, taut throat and difficulty speaking

• A racing heart

• Rapid breathing

• Nausea or discomfort lightheadedness

• Jitters; Shakiness in your hands, jaw and lips

• Sweating, especially from your hands  

These symptoms of performance anxiety don’t just develop out of nowhere. Instead, they’re a physical reaction caused by the presence of specific stress hormones in your body, particularly the hormones adrenaline (epinephrine) and noradrenaline (norepinephrine).

When you feel nervous and stressed, such as before delivering a speech, your body ramps up its production of these stress hormones. These hormones work by attaching to beta receptors throughout your body.

Once these hormones attach to your beta receptors, they trigger the anxiety symptoms listed above, from shaky hands to sweating, nausea and a rapid heartbeat.

According to an article published in the book, StatPearls, propranolol works by blocking these receptors. With these receptors blocked, stress hormones like adrenaline don’t have their normal effects on your heart and other tissue. This means you’re less likely to experience physical symptoms like shaking, sweating or a rapid pulse.

Since propranolol only blocks beta receptors, it doesn’t actually stop the psychological effects of anxiety. You might still feel nervous before delivering a speech or meeting someone, but it’s less likely to result in any kind of physical reaction.

Interestingly, although propranolol doesn’t directly affect your brain, it can help to make you feel less nervous. Without the shaking, rapid heartbeat and sweating that usually happens when you feel anxious, it can become easier to relax, perform and stay focused.

A review published in the Journal of Psychopharmacology shows that propranolol works best as a short-term treatment for specific types of anxiety, such as performance anxiety, social anxiety and specific phobias. Propranolol isn’t beneficial for treating other types of anxiety, such as generalized anxiety disorder.

Propranolol is a prescription medication, meaning you’ll need to talk to your healthcare provider before you can buy and use it.

Using propranolol to treat performance or social anxiety is a simple process. Many people prescribed propranolol off-label take 10mg to 80mg of propranolol approximately one hour before the event that’s likely to cause stress, depending on the severity of their anxiety.

However, only use the dosage recommended by your healthcare provider.

According to the FDA, propranolol has a half-life of three to six hours, meaning it can last a few hours with one dose. Using a lower dose of propranolol than is recommended by your healthcare provider can reduce the drug’s effects and provide shorter-acting relief from anxiety symptoms.

Like with other medications for anxiety, it can take time to work out the right dose of propranolol for you.

Most healthcare providers recommend starting with a low to moderate dose and adjusting your dose based on your results and side effects.

Benzodiazepines such as alprazolam (Xanax) and diazepam (Valium) are also commonly used to treat anxiety.

Although they might seem similar, beta blockers such as propranolol differ from benzodiazepines in several ways:

• Propranolol is not physically addictive. Although it’s possible to abuse propranolol and other beta blockers, these drugs aren’t physically addictive. Benzodiazepines such as Valium and Xanax, on the other hand, have a high risk of causing physical addiction.

• Propranolol is designed for short-term, event-based anxiety. Benzodiazepines are normally prescribed for long-term, generalized anxiety, whereas propranolol works best as a treatment for short-term, event-based anxiety.

• Propranolol primarily affects the body’s response to stress, not the brain. Benzodiazepines like Xanax® reduce anxiety by targeting parts of the brain and central nervous system. Propranolol primarily works by targeting the heart and other tissue with beta receptors.

In general, propranolol works best as a treatment for event-based anxiety, whereas drugs like benzodiazepines and SSRIs are normally used to treat recurrent, persistent anxiety disorders that aren’t triggered by specific events or settings.

Used responsibly at a normal dose, propranolol is a safe, effective treatment for performance and social anxiety. However, like other beta blockers, it can result in some side effects.

Side effects are typically mild and uncommon but can still affect you, especially after you first begin using the medication. According to an article published in the journal StatPearls, common side effects of propranolol include:

• Slower-than-normal heart rate. Because propranolol blocks the effects of adrenaline on your heart, it can give you a slow heart rate. It’s completely normal to experience a lower heart rate after you take propranolol. However, if your resting daytime heart rate drops below 50 beats per minute while using propranolol, you should contact your healthcare provider as soon as possible.

• Sleep problems. The American Journal of Medicine and the FDA published reports of insomnia, awakenings at night and other sleep problems while taking propranolol for hypertension. Several beta blockers are also linked to vivid and unusual dreams.

• Fatigue. Propranolol can make you feel more tired than normal due to its effects on the way your body responds to stress hormones. This is most common after you first start to use the medication and usually stops occurring after several days or weeks.

• Diarrhea. According to the FDA, ome people who use propranolol might experience diarrhea shortly after taking the medication. Propranolol can also cause nausea, especially in the first few weeks of treatment.

• Hair loss. Information published by the FDA says that propranolol is one of several beta blockers that can cause hair loss. The hair loss from propranolol is not permanent and is typically a result of the medication causing some hair follicles to enter their shedding phase prematurely.

• Dry eye syndrome. Propranolol and other beta blockers can cause you to develop dry eyes, potentially resulting in eye irritation, according to the FDA.

According to an article published by the Official Journal of Indian Academy of Neurology, propranolol is generally safe and side effects are usually mild and can be managed. If you experience any of the above side effects from propranolol, it’s best to contact your healthcare provider. 

Many of these effects can be reduced or avoided by adjusting your propranolol dose or switching beta blockers.

Propranolol also has the potential for several serious potential side effects, according to the FDA. These are rare and only affect a tiny percentage of users. 

However, if you experience any of the side effects listed below, or experience an allergic reaction to propranolol, you should seek help from your healthcare provider as soon as possible:

• Noticeably cold hands and/or feet

• Chest pains (angina)

• Congestion or sinus issues

• Low blood sugar

• Persistent insomnia or nightmares

• Hallucinations

• Difficulty breathing

• Resting heart rate below 50 beats per minute (bradycardia)

• Rapid weight gain and/or fluid retention in the legs and ankles

• Severe nausea, diarrhea or vomiting

Failure to seek immediate medical attention for serious side effects could result in heart failure, kidney disease or failure, or death. 

Signs of an allergic reaction to propranolol include rash, wheezing, chest or throat tightness, trouble breathing or talking, and facial, lip, mouth or throat swelling. 

Propranolol interactions occur with a variety of other medications. Some of these interactions are listed below.

According to the FDA, major propranolol interactions can occur with antiarrhythmic drugs (which are used to treat heart rhythm problems) and hypertension drugs, such as calcium channel blockers, alpha blockers and angiotensin-converting enzyme (ACE) inhibitors.

Propranolol can also interact with other beta blockers, meaning you should never take it with drugs such as acebutolol, atenolol, bisoprolol, carteolol, esmolol, metoprolol, nadolol, nebivolol or sotalol. Used with propranolol, these drugs can cause a dangerous drop in your heart rate.

Propranolol should not be used with lisinopril or enalapril (both ACE inhibitors), with diltiazem (a calcium channel blocker), or with prazosin, terazosin or doxazosin (all alpha blockers). Propranolol interactions may also occur with certain asthma medications, such as theophylline or any nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen.

Due to its effects on heart rate and blood pressure, propranolol is not recommended for use with any stimulants, such as epinephrine, isoproterenol or dobutamine. 

Propranolol can also interact with some blood thinners, such as warfarin, causing an increase in warfarin concentration, and with antidepressants such as sertraline.

Your healthcare provider might also recommend avoiding common stimulants such as caffeine, as these can affect the effectiveness of propranolol. 

Propranolol can also affect your body’s ability to process high-potassium foods.

Since propranolol is a prescription drug, you’ll need to talk to your healthcare provider before you’re able to use it. 

Make sure you inform your healthcare provider of all medications you use on a regular basis to avoid any potential drug interactions.

Is it Safe to Take Propranolol With Alcohol?

Propranolol should not be used with alcohol. One study published by the NIH found that consuming alcohol while you’re under the effects of propranolol can increase the chance of low blood pressure, causing you to feel lightheaded and sleepy. Additionally, the FDA recommends not mixing alcohol and propranolol.

Seek immediate medical attention if you experience serious withdrawal effects such as chest pain that worsens or spreads to the neck, jaw or arm, difficulty breathing or tightness in your chest or irregular heartbeat. 

Before taking propranolol, be sure to discuss any other existing medical conditions with your healthcare provider, such as history of heart attack. Patients with diabetes may be at risk for low blood sugar due to propranolol, according to the FDA. 

Additionally, if you have a chronic lung disease, such as emphysema or COPD, it is important to talk with your healthcare provider before taking propranolol in order to be properly monitored during your use.

Can You Overdose on Propranolol?

Yes. If you take too much propranolol, your heart rate can slow so much that it will be difficult to breathe. 

Always take propranolol exactly as prescribed and if an overdose is suspected, seek emergency medical care.

Propranolol is one of several beta blocker medications used to treat heart conditions, some types of anxiety, migraines and other conditions. 

Our guide to beta blockers goes into more detail on how beta blockers work.