What is more effective for social anxiety, hydroxyzine or propranolol?

Propranolol is Not Recommended for Social Anxiety Disorder

Neither hydroxyzine nor propranolol should be used as first-line treatment for social anxiety disorder, but if forced to choose between these two options, hydroxyzine has marginally more evidence—though both are inferior to guideline-recommended therapies. The most recent clinical practice guidelines explicitly deprecate beta-blockers like propranolol for social anxiety disorder based on negative evidence 1.

Guideline-Recommended Treatment (What You Should Actually Use)

The 2023 Japanese Society of Anxiety and Related Disorders/Japanese Society of Neuropsychopharmacology guidelines provide clear recommendations for social anxiety disorder 2:

First-line pharmacotherapy:

• Selective serotonin reuptake inhibitors (SSRIs) are the recommended pharmacological treatment (GRADE 2C, weak recommendation/low certainty evidence) 2
• Sertraline and escitalopram are preferred due to favorable safety profiles and lower discontinuation symptoms 1
• Venlafaxine (SNRI) is suggested as an alternative (GRADE 2C) 2

First-line psychotherapy:

• Cognitive behavioral therapy (CBT) specifically developed for social anxiety disorder (Clark and Wells model or Heimberg model) through individual sessions is recommended 2
• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness 1

Why Propranolol is Inappropriate

Beta-blockers (including propranolol) are explicitly deprecated for social anxiety disorder based on negative evidence 1. The evidence base shows:

• Propranolol is widely used for performance anxiety and public speaking anxiety (situational anxiety), but this is distinct from social anxiety disorder 3
• A 2024 randomized controlled trial in autism spectrum disorder found propranolol did not impact social interaction measures, though there were indications of benefit for anxiety symptoms (p = 0.045) 3
• The single case report available describes propranolol abuse in a patient with severe social anxiety disorder where symptoms persisted despite informal self-prescription for six years at doses up to 320 mg/day 4
• The patient's social anxiety only improved after proper treatment with tranilcipromine and paroxetine (an SSRI) 4

Why Hydroxyzine is Also Inappropriate (But Slightly Less So)

Hydroxyzine has evidence for generalized anxiety disorder (GAD), not social anxiety disorder—these are distinct conditions 5, 6, 7:

• A 2010 Cochrane review found hydroxyzine more effective than placebo for GAD (OR 0.30,95% CI 0.15 to 0.58), but concluded it cannot be recommended as reliable first-line treatment due to high risk of bias in studies, small sample size, and lack of data on social anxiety disorder specifically 5
• Hydroxyzine at 50 mg/day showed anxiolytic effects beginning in the first week for GAD, but the most common side effect was transient sleepiness (28% vs 14% with placebo) 7
• No evidence exists supporting hydroxyzine for social anxiety disorder specifically

Clinical Algorithm for Social Anxiety Disorder

Step 1: Initiate first-line treatment

• Start escitalopram 5-10 mg daily or sertraline 25-50 mg daily 1
• Titrate escitalopram by 5-10 mg increments every 1-2 weeks to target 10-20 mg/day 1
• Titrate sertraline by 25-50 mg increments every 1-2 weeks to target 50-200 mg/day 1
• Refer for individual CBT specifically designed for social anxiety disorder 2

Step 2: Assess response at 6-8 weeks

• Expect statistically significant improvement by week 2, clinically significant improvement by week 6, maximal benefit by week 12 1

Step 3: If inadequate response after 8-12 weeks at therapeutic doses

• Switch to a different SSRI or try venlafaxine extended-release 75-225 mg/day 1
• Ensure CBT is implemented if not already 1

Critical Pitfalls to Avoid

• Do not use propranolol for social anxiety disorder—it is deprecated by guidelines and lacks efficacy evidence for this condition 1
• Do not confuse performance anxiety (situational) with social anxiety disorder (generalized)—propranolol may have a role in performance anxiety but not in the broader disorder
• Do not use hydroxyzine as first-line—evidence is limited to GAD, not social anxiety disorder 5
• Avoid paroxetine due to higher discontinuation symptoms and potentially increased suicidal thinking 1
• Monitor for initial anxiety/agitation when starting SSRIs, which typically resolves within 1-2 weeks 1