Is propranolol (beta blocker) effective for treating anxiety?

Propranolol for Anxiety

Propranolol is effective for situational performance anxiety (stage fright, public speaking) but is NOT recommended as first-line therapy for generalized anxiety disorder, panic disorder, or chronic social anxiety disorder. 1, 2

Clinical Algorithm for Propranolol Use in Anxiety

When to Use Propranolol

For situational/performance anxiety (isolated events):

• Prescribe propranolol 20-40 mg taken 1 hour before the anxiety-provoking event 1
• This is appropriate for infrequent public speaking, stage performances, or test-taking anxiety 1
• Have the patient trial the dose before an important event to assess individual response and tolerability 1

For anxiety with prominent somatic symptoms:

• Propranolol may provide symptomatic relief when physical symptoms (tremor, palpitations, tachycardia, nervousness) predominate 1, 3
• Consider doses of 20-40 mg once to three times daily for anxiety characterized by increased adrenergic tone 4
• Propranolol is more effective than placebo specifically in patients with somatic anxiety, but not in those with primarily psychic anxiety 3

When NOT to Use Propranolol

Chronic anxiety disorders require different treatment:

• SSRIs and SNRIs are first-line pharmacotherapy for generalized anxiety disorder, panic disorder, and chronic social anxiety disorder 1, 2
• Canadian Clinical Practice Guidelines and Japanese guidelines explicitly deprecate propranolol for chronic social anxiety disorder 1, 2
• For frequent or chronic performance anxiety, cognitive behavioral therapy (CBT) is first-line, and if pharmacotherapy is needed chronically, use SSRIs/SNRIs, not beta-blockers 1

Limited efficacy in panic disorder:

• Propranolol is not recommended for panic disorder as a primary treatment 1, 5
• It may be combined with SSRIs/CBT for residual somatic symptoms (palpitations, tachycardia) only 1, 5

Mechanism of Action

• Propranolol blocks peripheral beta-adrenergic receptors, reducing physical manifestations of anxiety including rapid heart rate, tremors, and nervousness caused by adrenaline 1, 2
• The medication does not address the cognitive or psychological components of anxiety 2

Critical Contraindications and Precautions

Absolute contraindications:

• Asthma or chronic obstructive pulmonary disease 1
• Bradycardia or heart block 1
• Heart failure or decompensated systolic heart failure 1
• Severe hypotension or cardiogenic shock 1

Important warnings:

• Use with caution in diabetes as propranolol may mask hypoglycemia symptoms 1
• May induce depression in predisposed patients—use cautiously if concurrent depressive illness exists 5
• Never abruptly discontinue after regular use due to risk of rebound symptoms 1
• Common side effects include bradycardia, hypotension, fatigue, cold extremities, and sleep disturbances 1

Practical Pitfalls to Avoid

• Do not prescribe propranolol for chronic daily use in generalized anxiety—this is ineffective and guidelines recommend against it 1
• Do not use as monotherapy for panic disorder—preliminary research shows poor efficacy 5
• Screen for asthma/COPD before prescribing—this is a common and dangerous oversight 1
• Efficacy beyond 4 weeks of continuous use is not well-established 4