Performance anxiety

By Harvey B. Simon, M.D.
Content provided by the Faculty of the Harvard Medical School

Q. I am a 38-year-old junior executive. My work gets good marks from my supervisors, but I have a problem that may hamper my career. Every time I have to make a presentation, I get terribly nervous, making it very hard for me to get through my talk. I've heard there is a pill that can help, but I don't want to take tranquilizers. What do you suggest?

A. Although your symptoms occur in a corporate boardroom, not a theatre, your problem is best known by its popular name, stage fright. It's a common problem that doctors diagnose as performance anxiety. And it responds beautifully to treatment.

The best drugs are beta blockers. First introduced for the treatment of angina around 1970, these medications are not tranquilizers or sedatives. They don't help ordinary anxiety, they're not habit forming, and they don't act on the central nervous system. Instead, they slow the heart rate, lower the blood pressure, and help calm certain tremors.

In addition to treating angina and hypertension, beta blockers have proven useful for heart failure, certain disorders of the heart's pumping rhythm, essential tremors, and migraine prevention. In the case of performance anxiety, the drugs work by preventing your heart rate from racing when you start to speak in public. Without a racing heart, your body doesn't signal anxiety — because your body feels calm, your mind stays calm. It's a nice example of the unity of mind and body; when your body's response to mental stress is blunted, your mind is tricked into feeling calm and confident.

Beta blockers are prescription drugs, and they should be used with care, especially by people who have asthma or diabetes and by people taking other cardiovascular medications. But since only a single low dose is required, beta blockers are safe for nearly everyone with performance anxiety. Doctors often prescribe propranolol (Inderal and other brands) in a dose of 10 to 20 milligrams to be taken about 30 minutes before public speaking. If your doctor agrees with this approach and gives you a prescription, take a test run before your big presentation to be sure the dose works for you.

Although beta blockers provide a simple solution for most folks with performance anxiety, there are alternatives. Cognitive behavioral therapy can help, as can coaching or classes in public speaking. Finally, be sure that your stage fright is not a symptom of social anxiety disorder, a more troublesome problem that produces distress during a broad array of interpersonal interactions. Social anxiety disorder also responds well to treatment, but beta blockers won't do the job.

If your problem is simple stage fright, a beta blocker should soon have you taking bows.

— Harvey B. Simon, M.D.
Editor, Harvard Men's Health Watch

Last Annual Review Date: 2009-10-01T00:00:00-06:00 Copyright: Copyright Harvard Health Publications

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Anxiety costs the United States more than $42 billion every year-that's almost a third of the country's total mental health bill.