Is it safe to continue propranolol (beta blocker) in a patient with emerging delusional symptoms while being treated for anxiety?

Discontinue Propranolol in Patients with Emerging Delusional Symptoms

Propranolol should be discontinued immediately in patients who develop delusional symptoms while taking it for anxiety, as beta-blockers can potentially exacerbate or trigger psychiatric symptoms including delusions. 1

Relationship Between Propranolol and Psychiatric Symptoms

• Beta-blockers, particularly propranolol, have been documented to cause mental status changes including paranoid delusions, especially in vulnerable populations 1
• Case reports have shown that even low doses of propranolol (as little as 10mg) can trigger manic symptoms in susceptible individuals 2
• Psychiatric side effects can occur without evidence of cardiovascular instability and may resolve within a week of discontinuation 1

Alternative Treatments for Anxiety

First-line Pharmacological Options:

• SSRIs such as escitalopram, sertraline, fluvoxamine, and paroxetine are recommended as first-line treatments for anxiety disorders 3
• SNRIs like venlafaxine are also considered first-line options with good efficacy 3

Second-line Options:

• Benzodiazepines may be used for short-term management of acute anxiety symptoms 3
• Buspirone can be useful for patients with mild to moderate anxiety and may take 2-4 weeks to become effective 3

Management of Patients with Delusional Symptoms

• For patients with emerging delusional symptoms, antipsychotic medications should be considered 3
• Second-generation antipsychotics such as olanzapine (2.5-5mg), quetiapine (25mg), or risperidone (0.5mg) may be appropriate 3
• Third-generation antipsychotics like aripiprazole (5mg) have fewer extrapyramidal side effects and may be beneficial 3

Monitoring and Follow-up

• After discontinuing propranolol, monitor for resolution of delusional symptoms, which typically occurs within one week 1
• If symptoms persist despite discontinuation, psychiatric consultation is warranted for comprehensive evaluation 3
• Carefully assess for other potential causes of delusional symptoms, including underlying psychiatric disorders that may have been unmasked by propranolol 2

Important Considerations

• Beta-blockers like propranolol are primarily beneficial for somatic anxiety symptoms (physical manifestations) rather than psychic anxiety (psychological symptoms) 4, 5
• The Canadian Clinical Practice Guidelines specifically deprecate the use of beta-blockers like propranolol for social anxiety disorder based on negative evidence 3
• While propranolol has been used for specific indications such as performance anxiety, panic disorder, and essential tremor, its use in patients with psychiatric symptoms requires caution 3

Pitfalls to Avoid

• Do not continue propranolol in the presence of delusional symptoms, as rechallenge has been shown to cause recurrence of mental status changes 1
• Avoid assuming that anxiety symptoms will improve with continued beta-blocker therapy when psychotic symptoms have emerged 2
• Do not overlook the possibility that propranolol may unmask or exacerbate underlying bipolar disorder or other psychiatric conditions 2