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 Indications Where Propranolol Works

Performance Anxiety (Primary Indication)

• Propranolol 20-40 mg taken 1 hour before a performance or public speaking event is the recommended approach for situational anxiety. 1
• The mechanism involves blocking peripheral beta-adrenergic receptors, which reduces physical symptoms like rapid heart rate, tremors, and nervousness caused by adrenaline during performance situations. 1
• The American College of Cardiology recommends this single-dose strategy for situational use, not chronic daily therapy. 1
• Always advise patients to trial the dose before an important event to assess individual response and tolerability. 1

Anxiety with Prominent Physical Symptoms

• Propranolol may provide symptomatic relief for anxiety disorders characterized by somatic symptoms related to increased adrenergic tone (palpitations, tremor, tachycardia). 1, 3
• Historical research shows propranolol was more effective than placebo specifically in patients with somatic anxiety, but not in those with primarily psychic anxiety. 3
• This represents a niche role, typically as adjunctive therapy when physical symptoms persist despite standard treatment. 4

Where Propranolol Does NOT Work (Critical Pitfall)

Generalized Anxiety Disorder and Chronic Social Anxiety

• Canadian Clinical Practice Guidelines and Japanese guidelines explicitly deprecate propranolol for chronic social anxiety disorder. 1, 2
• SSRIs and SNRIs are first-line pharmacotherapy for generalized social anxiety and generalized anxiety disorder, with stronger evidence for efficacy. 1, 2
• The Neuropsychopharmacology guidelines specifically state propranolol is not recommended for generalized anxiety disorder or chronic anxiety. 1

Panic Disorder

• Propranolol is not effective as primary treatment for panic disorder. 4
• It may be used for residual somatic complaints (palpitations, tachycardia) when combined with SSRIs/SNRIs and cognitive behavioral therapy, but this is a limited adjunctive role. 1, 4

Treatment Algorithm

For situational/performance anxiety (infrequent events):

• Screen for contraindications (see below). 1
• Prescribe propranolol 20-40 mg to take 1 hour before the event. 1
• Have patient trial the dose before an important event. 1

For frequent or chronic performance anxiety:

• Cognitive behavioral therapy (CBT) is first-line treatment. 1
• If pharmacotherapy is needed chronically, use SSRIs/SNRIs, not beta-blockers. 1
• CBT shows superior outcomes for chronic performance anxiety compared to propranolol. 1

For generalized anxiety disorder or panic disorder:

• Do not use propranolol as primary therapy. 1, 2
• Use SSRIs/SNRIs as first-line pharmacotherapy. 1, 2
• Consider CBT as first-line non-pharmacological treatment. 1, 2

Critical Contraindications and Precautions

Absolute contraindications: 1, 2

• Asthma or chronic obstructive pulmonary disease
• Bradycardia
• Heart block (greater than first degree without pacemaker)
• Decompensated heart failure
• Cardiogenic shock

Use with caution: 1

• Diabetes (propranolol may mask hypoglycemia symptoms)
• Patients at risk for depression (beta-blockers may induce depressive states)

Common side effects: 1

• Bradycardia
• Hypotension
• Fatigue
• Cold extremities
• Sleep disturbances

Never abruptly discontinue propranolol after regular use, as this can lead to rebound symptoms. 1

Key Clinical Pearls

• The effectiveness of propranolol for anxiety is limited to acute situational use and anxiety with prominent physical symptoms—it is not a broad-spectrum anxiolytic. 1, 3
• For isolated, infrequent public speaking events, propranolol is more practical than multi-session therapy programs. 1
• The American College of Surgeons recommends propranolol for surgeons experiencing procedural anxiety, as it reduces physiologic tremor and heart rate. 1
• Some evidence suggests propranolol may reduce arousal symptoms in PTSD, though this is based on small studies and is not a primary indication. 1