Propranolol for Situational Panic Attacks

For some people, a little pill every once in a while can be life changing.

Propranolol is a prescription medication that blocks adrenaline receptors in the body. It is indicated for the treatment of high blood pressure, certain arrhythmias, migraine prevention, essential tremor, and a few other more rare conditions. But it can also be used off-label to block powerful, disabling surges of adrenaline. These surges are the physiologic basis of panic attacks in situations like public speaking and performances. Propranolol can steady the pounding heart, the surging of blood pressure, the quavering voice, the trembling hands - and by extension may calm a sense of imminent doom that comes from a body awash in fight-or-flight hormones.

As I watched the above interview with musician Tobias Jesso, who is nominated for Songwriter of the Year in this year’s Grammy awards on February 5th, I couldn’t help but wonder if a doctor ever offered him a trial of propranolol for his performance anxiety.

He candidly discusses how uncomfortable and stressful performing as a musician in front of a crowd is for him, and how this led him to become a songwriter instead. He’s doing quite well in this pursuit, writing hit songs recently for Adele, Orville Peck, and Harry Styles among others. But extreme situational performance anxiety can culminate in disabling panic attacks, and many doctors fail to consider how a dash of beta-blocking propranolol might be used to keep life’s doors open.

But first, back to Tobias Jesso. In the above clip he explains how he always wanted to be a musician and write songs, but that his “nervous system” would not allow him to feel comfortable performing on stage. The severe anxiety caused him to walk away from the spotlight after his first solo album release. I think his insight here is spot on. Our sympathetic nervous system is responsible for the fight-or-flight response to perceived danger, and can be triggered by saber-toothed cats, or simply standing alone and exposed, apart from the herd, sweating under a spotlight while thousands of other people look at us. And it only takes one panic attack in such a situation to burn the experience into our nervous system’s reactionary toolkit. We worry the misery will recur. For some it feels as miserable as imminent death.

Situational panic attacks should be distinguished from generalized anxiety and panic disorder. It seems like the majority of people I see have some level of anxiety, and it often reaches the threshold of dysfunction. Pervasive anxiety and panic attacks in general are a topic for a different discussion.

This discussion is about more specific situations. Over the years I have heard stories from my patients about how a fear of public speaking closed doors to career advancement. Recently someone told me about how he had to give up his chance to go to Julliard and become an elite professional musician. Taking deep breaths, asserting control from our prefrontal cortex over the fearful amygdala, and picturing the audience naked might work for some… and we should always seek help and work on anxiety reduction in comprehensive ways. But the flood of chaos in the nervous system that I suspect Tobias Jesso might be describing can also be simply blocked with a little pill, taken as needed, sparingly. If we need validation from other celebrities, a quick online search reveals that stars like Katy Perry, Khloe Kardashian, Richard Branson, Bobby Lee, Shawn Mendes, and Blair Tindall have all admitted to taking propranolol to help with panic attacks while performing. I guarantee there are thousands more.

Propranolol blocks the extremely uncomfortable physiologic effects that are felt during an attack. These symptoms can otherwise have a snowballing effect - heart pounding leads to more heart pounding leads to a full-on avalanche of embarrassment and adrenaline shame. Performers and speakers can have absolute clarity about what’s going on, and tell themselves this reaction is stupid - but the competing nervous systems in the body and mind are not completely under our conscious control. Yet every time someone succeeds in harrowing situations, maybe with some beta-blocking help, this builds confidence and helps to extinguish the neural pathway that has burned a dysfunctional trail. I have seen short term use effect some long term cures.

Examined presents vital and overlooked ideas your primary care doc might share - if only we had more time

Propranolol is not risk free, but it is safe for most people, especially at the low doses which are effective for situational panic. Propranolol does not cause much sedation, and is much better than benzodiazepines like Xanax and Ativan for people not wanting to dim their wits. It blocks what’s going on below the brain. It should not be prescribed if a person has contraindications. It can lower blood pressure. Always consult with your doctor, and never take something without a full discussion and a legal prescription.

The renowned painter Edvard Munch was known to suffer from extreme anxiety and panic attacks. His famous work entitled The Scream was painted to convey the horror of total isolation felt by a single being, and was inspired by his panic attacks.

Image from National Gallery of Norway, Public Domain - Edvard Munch

I don’t know if Munch would have benefited from propranolol. Probably not, since his anxiety was more pervasive, and not simply triggered by getting on stage or on camera to paint. Painters don’t have to do that. Except Bob Ross, who had a sublime, guru-type voice that maybe he channeled to crush some demons. He was a former marine who fought in Vietnam after all.

I’ll close this post by prompting you or someone you care about to discuss with a physician all options for treating disabling situational anxiety. It might change the course of someone’s life, career, or happiness. Propranolol is off label, but should be on the table. And finally, I asked the artificial intelligence of a program called DALL-E to compose:

a painting in the style of Edvard Munch depicting a man having a panic attack while giving a speech to a crowd

This is the pretty awesome, computer generated portrait below. One day, if Examined ever achieves a sufficient number of paid subscribers, I will totally and preferentially and honorably pay a human artist to compose artwork to go along with my writing. But on a low budget, this AI tool expresses what I’ve been trying to describe about situational panic attacks quite well…

Original artwork, composed by me and the machine

Take good care, and I hope Tobias Jesso does win the Grammy for Songwriter of the Year. Tobias - please call me if you want to discuss how I might help you rock your acceptance speech :) I occasionally dabble in rhythms, too.