What is the recommended dose of propranolol (beta blocker) for treating physical symptoms of anxiety in adults?

Propranolol Dosing for Physical Symptoms of Anxiety in Adults

For adults with physical symptoms of anxiety, propranolol should be initiated at 10-40 mg taken 30-60 minutes before anxiety-provoking situations for situational anxiety (such as performance anxiety), or 20-40 mg two to three times daily for generalized physical anxiety symptoms, with typical maintenance doses ranging from 80-160 mg daily in divided doses. 1, 2

Dosing Strategy Based on Anxiety Pattern

For Situational/Performance Anxiety

• Start with 10-40 mg as a single dose 30-60 minutes before the anxiety-provoking event (e.g., public speaking, social situations) 1, 3
• This approach is most effective for predictable, time-limited situations where physical symptoms predominate 1
• A 40 mg single dose has been specifically validated for reducing observable anxiety behaviors and physiological symptoms in performance situations 3

For Chronic Physical Anxiety Symptoms

• Begin with 20-40 mg two to three times daily (60-120 mg total daily dose) 1, 2
• Adjust dosage to achieve clinical response and significant beta-blockade, evidenced by virtual abolition of orthostatic and hyperventilatory tachycardia 2
• Typical effective range is 80-320 mg daily in divided doses, though most patients respond to doses under 160 mg daily 2
• Maximum doses up to 1200 mg daily have been used temporarily for severe or refractory symptoms, though this is uncommon 2

Patient Selection Criteria

Propranolol is most effective for patients whose anxiety manifests predominantly as somatic (physical) symptoms rather than purely psychological symptoms 4. Key indicators include:

• Tremor, palpitations, tachycardia, sweating, and other autonomic symptoms 1, 4
• Moderate intensity anxiety, particularly in primary care settings 1
• Recent onset symptoms not meeting criteria for chronic anxiety disorders 1
• Limited number of predictable anxiety-provoking situations 1

Propranolol showed no advantage over placebo in patients with predominantly psychic (psychological) anxiety symptoms 4, making patient selection critical for treatment success.

Mandatory Pre-Treatment Assessment

Before initiating propranolol, exclude the following absolute contraindications 5, 6:

• Second or third-degree heart block (in absence of pacemaker) 5
• Decompensated heart failure or significant left ventricular dysfunction 5
• Asthma or reactive airway disease/obstructive lung disease 5, 6
• Hypotension or cardiogenic shock 5
• Recent or ongoing hypoglycemic episodes 6
• Sinus node dysfunction (without pacemaker) 5

Perform baseline assessment including:

• Heart rate and blood pressure measurement 5, 6
• Cardiovascular examination with auscultation 5
• Screen for history of bronchospasm, diabetes (propranolol masks hypoglycemia symptoms), and concurrent medications that affect cardiac conduction 5, 6

Monitoring and Titration

• Monitor for hypotension and bradycardia, especially during dose escalation 5, 6
• For chronic treatment, reassess after 2-4 weeks as efficacy beyond 4 weeks of continuous use is not well-established 1
• Adjust dose based on clinical response and tolerability, with most patients achieving benefit at 80-160 mg daily 2
• Routine heart rate and blood pressure monitoring between appointments is not required for stable patients without complications 6

Critical Safety Considerations

Never abruptly discontinue propranolol after chronic use, as this can precipitate rebound hypertension, tachycardia, or angina 6. Taper gradually when discontinuing.

Common adverse effects to counsel patients about 5:

• Fatigue and bradycardia (dose-related)
• Hypotension and dizziness
• Cold extremities
• Potential for worsening heart failure in susceptible patients
• Masking of hypoglycemia symptoms in diabetics 6
• Possible cognitive effects and mood changes, though this remains controversial 1

Duration of Treatment

• For situational anxiety, use on an as-needed basis before predictable anxiety-provoking events 1
• For chronic symptoms, treatment duration should be limited to several weeks to months rather than indefinite use 1, 2
• Many patients experience lasting remissions after successful treatment periods, allowing dose reduction or discontinuation 2
• If symptoms persist beyond 4 weeks without adequate response, reassess diagnosis and consider alternative treatments 1

Comparative Context

While propranolol effectively treats physical anxiety symptoms, it should be considered alongside or as an alternative to benzodiazepines and antidepressants rather than as first-line monotherapy for all anxiety disorders 1, 7. Its specific niche is in patients with predominantly somatic symptoms who wish to avoid benzodiazepine-related sedation, psychomotor impairment, or dependence risk 1, 7.