Performance anxiety is a common psychological condition. It includes stage fright (when you have to speak or perform in front of a large or unfamiliar audience), test-taking anxiety, and — not uncommon among young men — sexual performance anxiety. The situations that trigger anxiety vary but the common emotion is a fear that you won’t live up to other people’s expectations, make a fool of yourself, or fail at an important task.
Virtually all people will experience performance anxiety at least once in their lives – think wedding, a critical exam, career discussions with the boss, etc. — and it’s nothing to worry about. However, some people struggle with more severe cases of performance anxiety, and often it comes with the their job. For example, musicians, actors, politicians and other public presenters are groups prone to more frequent performance anxiety.
The typical physical symptoms accompanying a performance anxiety attack include a rapid heartbeat, sweaty palms, dry mouth, tremors, dizziness, a shaky voice, and stuttering.
A wide range of effective treatments are available to reduce performance anxiety, including meditation and other mental exercises, as well as medications. As for the latter, the two most commonly prescribed medications are benzodiazepines and propranolol.
Benzodiazepines (commonly known as “benzos”) are a family of the drugs that have a tranquilizing effect and thus have been used to treat anxiety disorder, agitation, muscle spasms, and many other conditions for nearly six decades. Benzos work by boosting the effectiveness of a brain chemical (called GABA) that dulls the excitability of neurotransmitters. Diazepam (generic Valium) and alprazolam (Xanax) are the most commonly prescribed of this group. In most countries, benzos regularly feature among the 100 most prescribed drugs.
Propranolol (Inderal) belongs to a family of medications known as beta-blockers. In fact, it belongs to the first generation of beta-blockers and its original purpose was to treat patients with high blood pressure (hypertension) and various heart issues. Propranolol works its magic by reducing the impact of adrenaline on the body. This can in turn, reduce the heart rate, lower blood pressure and reduce both sweating and tremors. Beta-blockers have been used to treat anxiety disorders for over 30 years.
The chief difference between benzos and propranolol lies in the way the drugs work. Benzos target the brain and central nervous system, whereas propranolol is focused on the cardiovascular system. The former primarily has a psychoactive impact, while the latter mostly influence you physically (although the act of taking a beta-blocker in itself has a reassuring psychological effect).
Since propranolol’s effect on the body is more straight-forward and doesn’t require re-wiring the brain, it only takes 30 to 60 minutes after taking a pill to yield the desired effect. This makes the drug useful for single-event performance anxiety, for example prior to an important presentation or test. In contrast, benzos typically are prescribed for medium-term treatment (several weeks to 4 months) to tackle more serious anxiety disorders. It takes several days and sometimes even weeks for benzos to reach their maximum effect, Additionally, at the end of the treatment period, the drug can’t be abruptly stopped but instead needs to be gradually phased out to avoid withdrawal-related side effects..
Benzos have a long track record and in general are considered safe (more on their common side effects below), as long as they are used in the short to medium term and in the doses prescribed by your doctor. However, if used for longer than a few months, they can form an addictive habit, where your body physically craves the medication. Benzodiazepine abuse is a widespread problem, which is why the more potent variations are banned in many countries. Benzodiazepine overdose can be fatal, and the risk of overdose is higher when combined with other drugs. In contrast, propranolol hasn’t been found to cause addiction, even after long-term use.
Your doctor will decide which drug is the best treatment for your specific case of anxiety. In general, if you are dealing with event-based anxiety that requires a one-off or infrequent treatment, propranolol or another beta-blocker is a preferable first choice. If you are struggling with a more profound anxiety disorder, your doctor may want to prescribe benzodiazepines for a short period, in addition to an anti-depressant or anti-anxiety medication such as Prozac for long-term treatment.
Possible side effects have to be differentiated by the treatment duration, e.g., whether it’s short or medium/long term. In the short term, the most common side effects of benzos include:
The following short-term side effects are less common:
If benzos are used for longer, especially if abused for recreatio, the following side effects have been observed in some people:
To learn more about other side effects and contraindications for benzodiazepines, talk to your doctor, and carefully read the manufacturer’s information of the drug you are taking.
Propranolol common side effects are mostly seen in continuous users, such as hypertension patients, and tend to occur in the first couple of weeks of treatment while the body is still getting used to the new medication. Even with infrequent or one-off use, the following common side effects may be observed:
More serious side effects may occur in less than 1% of patients. If you are taking propranolol and think you have any of the symptoms listed below, you should seek medical help:
To learn more about propranolol side effects, read the manufacturer’s leaflet or speak with a medical professional.
Financial considerations, unfortunately, can play a role in healthcare and medication choices, but this won’t be the case here. Generic benzos and propranolol both typically cost well below $1 per dose. Moreover, for treating performance anxiety you would take the medication infrequently. Therefore, you can simply can follow what your doctor thinks is the best treatment option as there is no significant cost difference.
Reviewed by Dr Roy Kedem, MD
Information last reviewed 10/13/21