A 24-year-old medical student has no difficulty in casual conversation or small group settings, but develops marked tremor, sweating, and tachycardia only when performing, such as playing piano at a recital or giving a presentation. He functions normally otherwise. Which is the most appropriate pharmacological intervention used prophylactically before such performances?

• A Sertraline daily for 8 weeks
• B Alprazolam three times daily for 4 weeks
• C Propranolol taken about an hour before the performance ✓
• D Phenelzine daily for 12 weeks

Explanation

Performance-only social anxiety responds to a single dose of a beta blocker such as propranolol taken 60 minutes before the event; it blunts peripheral adrenergic manifestations like tremor and tachycardia. Daily SSRIs are reserved for generalised social anxiety disorder, and MAO inhibitors such as phenelzine are third line because of toxicity. The narrow, performance-limited pattern is what makes propranolol appropriate here.

Reference: Kaplan and Sadock's Synopsis of Psychiatry, 12th ed.

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Written and medically reviewed by the StethoPrep medical team.