Two ways to quiet a moment, and what each one costs

TL;DR: These two drugs treat different halves of the same problem. A beta-blocker like propranolol works on your body. It stops the pounding heart and the shaking hands and leaves your mind clear and your reflexes normal. A benzodiazepine like alprazolam or lorazepam works on your brain. It takes the fear down, and it also slows your thinking, makes you sleepy, blurs your memory of the event, and can become something your body needs. For a talk, an audition, an exam, or an interview, most people are better served by the beta-blocker, because the sedation is a direct tax on the thing you are trying to do well. The benzodiazepine has a place, mostly for panic and for fear so intense that a person cannot enter the room at all. Both need a doctor. One of them is a controlled substance and needs an ongoing relationship instead of a form. Tell Dr. Ash what happens to you and he will tell you which half is your problem.

People arrive with the two of these already mixed up in their heads, usually because a friend swore by one and the internet recommended the other. They do not do the same job. Once you can see which half of the problem each one treats, the choice usually makes itself.

What is the difference between a beta-blocker and a benzodiazepine?

A beta-blocker works below the neck and a benzodiazepine works above it.

Propranolol occupies the beta-adrenergic receptors that adrenaline binds to in your heart, lungs, blood vessels, and skeletal muscle. Your nervous system still sends the alarm; the receptors no longer receive it. Your heart rate stays near baseline, the tremor never develops, the voice keeps its tone, and your thinking is untouched. The dread stays where it was.

Alprazolam, lorazepam, and diazepam bind to GABA-A receptors in the brain and increase the effect of GABA, the main inhibitory neurotransmitter in the central nervous system. That damps down neural excitability across the board. Anxiety falls, and so does alertness, reaction time, coordination, and the formation of new memories.

So the plain framing is this. A beta-blocker removes the physical evidence of fear. A benzodiazepine removes some of the fear and some of you along with it.

How do they compare side by side?

Guidance from the Clinic

"When somebody tells me the problem is that their hands shake, I know which drug we are talking about. When somebody tells me they cannot make themselves walk through the door, that is a different conversation, and a controlled substance is usually the third or fourth thing I would try there, well down my list."

Which one is better for a presentation, an audition, or an exam?

For a performance, the beta-blocker is usually the better fit, and the reason is the sedation.

Every one of these situations asks you to be sharp: to recall material, to read a room, to adjust in the moment, to play a passage you have practiced a thousand times. A benzodiazepine takes the edge off the fear and takes the edge off all of that too. Musicians describe the difference plainly. On a beta-blocker they play the way they play in the practice room. On a benzodiazepine they feel calmer and play worse, and afterwards they cannot fully remember the performance.

The memory effect deserves its own mention. Benzodiazepines impair the formation of new memories, which is a therapeutic feature during a colonoscopy and a loss during your daughter's wedding.

There is one more reason to think carefully before using a benzodiazepine here. If a large part of the goal is to learn that you can survive the room, a drug that removes both the fear and the memory of the event leaves you with very little to carry into the next one.

When is a benzodiazepine the better choice?

There are situations where it is, and pretending otherwise would be dishonest.

Panic attacks are the clearest. Panic is a brain event with a physical cascade attached, and blocking the cascade does very little for someone convinced they are dying. A short-acting benzodiazepine can abort a panic attack in a way a beta-blocker cannot.

Fear intense enough to prevent the attempt is the second. If someone cannot get onto the plane, into the MRI scanner, or into the dentist's chair at all, the goal is not a polished performance; it is getting through the thing. Sedation is acceptable when there is nothing to perform.

Situations with no performance demand attached are the third. A procedure, a scan, a long flight. Nothing is being asked of your reflexes, so the trade is much cheaper.

What all three share is that they are episodic uses with a defined end, decided by a clinician who knows the patient. None of them describes a monthly subscription arriving in the post.

What are the risks of each one?

The beta-blocker's risks are cardiopulmonary and they are avoidable by asking the right questions in advance. Asthma and reactive airway disease are the firmest stop, because non-selective beta-blockade can trigger bronchospasm. A slow resting heart rate, heart block, heart failure, and low blood pressure all rule it out. Insulin-treated diabetes needs a physician's review, since beta-blockade masks the warning signs of a low. The full list is on the page for who should not take propranolol.

The benzodiazepine's risks accumulate with use, which makes them harder to see at the start. Tolerance builds, so the same dose does less. Physical dependence follows repeated use, and stopping abruptly after regular use can cause withdrawal that includes seizures. Combined with alcohol or an opioid, benzodiazepines depress respiration, which is the mechanism behind a substantial share of overdose deaths. In older adults they raise the risk of falls and confusion. Anyone with a history of substance use disorder or with untreated sleep apnea is a poor candidate.

There is also a rebound problem specific to using them for anxiety. Anxiety often returns higher than baseline as the drug wears off, so a person who takes one before every difficult meeting can find the meetings getting harder over time instead of easier.

Can you take both?

Occasionally, and only with a clinician who knows your whole picture. Nothing about the two mechanisms conflicts, and there are people whose racing physiology and whose panic both need addressing.

The reason to be careful is that combining them makes it harder to know what is doing what, and it moves a person toward standing use of a controlled substance for a situational problem. If a beta-blocker alone is not enough, the more useful next question is usually whether the diagnosis is right, and whether what looks like stage fright is something that arrives every day.

What does Fishtown Medicine do with each of these?

Propranolol for situational performance anxiety is an evaluation and a decision: a screen for the airway, rate, conduction, pressure, and glucose problems that make beta-blockade unsafe, a look at whether the pattern is a moment or a life, and a prescription filled at whichever pharmacy is cheapest for you. The medicine is an inexpensive generic and there is no reason for anyone to mark it up.

Benzodiazepines are handled differently on purpose. They are controlled substances, so Fishtown Medicine prescribes them only within an established membership, only in Pennsylvania and New Jersey, with an in-person evaluation every 6 months, and never as chronic maintenance therapy. That is a deliberately narrow door. A drug with dependence potential needs a standing relationship and a follow-up rhythm, which is what a membership is and what a one-off transaction is not. The reasoning is published in full on the controlled substances policy.

What should you try before either of them?

Both of these are tools, and neither is a first move for most people.

Practice under conditions that resemble the day itself does more than either drug. Rehearsing a talk alone in your kitchen builds the material; rehearsing it standing up, out loud, in front of two people you find slightly intimidating builds the tolerance. Cognitive behavioural therapy has the strongest evidence base of anything here for social anxiety, and for many people it is curative in a way medication is not.

The ordinary physiological levers matter more than people expect. Sleep debt raises resting adrenaline. Caffeine on the morning of a performance works directly against you. Alcohol the night before fragments sleep and worsens the next day's anxiety. A person who fixes those three sometimes finds the problem has become manageable without anything else, and someone whose sleep is the root of it should start with insomnia instead.

Related at Fishtown Medicine

• Propranolol for performance anxiety
• Who should not take propranolol
• Performance anxiety: what your body is doing
• Is it anxiety or something else?
• Online mental health treatment

Scientific References

1. Brantigan CO, Brantigan TA, Joseph N. Effect of beta blockade and beta stimulation on stage fright. The American Journal of Medicine. 1982;72(1):88-94.
2. Steenen SA, van Wijk AJ, van der Heijden GJMG, van Westrhenen R, de Lange J, de Jongh A. Propranolol for the treatment of anxiety disorders: A systematic review and meta-analysis. Journal of Psychopharmacology. 2016;30(2):128-139.
3. Buffett-Jerrott SE, Stewart SH. Cognitive and sedative effects of benzodiazepine use. Current Pharmaceutical Design. 2002;8(1):45-58.
4. American Geriatrics Society. Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
5. US Food and Drug Administration. Benzodiazepine Drug Class Boxed Warning Update, 2020.
6. Mayo-Wilson E, Dias S, Mavranezouli I, et al. Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry. 2014;1(5):368-376.