Propranolol Should Not Be Used for Anxiety Disorders or Post-Acute Withdrawal Syndrome
Propranolol and other beta-blockers are explicitly not recommended for anxiety disorders based on negative evidence from multiple international guidelines, and there is no established role for propranolol in managing post-acute withdrawal syndrome (PAWS). 1
Evidence Against Beta-Blockers for Anxiety Disorders
Guideline Recommendations
The Canadian Clinical Practice Guideline explicitly deprecates beta-blockers (atenolol and propranolol) based on negative evidence for social anxiety disorder 1
The 2023 Japanese Society of Anxiety and Related Disorders guideline, citing the Canadian CPG, confirms that beta-blockers including propranolol are not recommended for anxiety disorders 1
A 2025 systematic review and meta-analysis found no evidence for beneficial effect of beta-blockers compared with either placebo or benzodiazepines in patients with social phobia or panic disorder (p-value ≥0.54 for all comparisons) 2
The Only Exception: Performance Anxiety
Beta-blockers may have extremely limited adjunctive use only for episodic performance anxiety (such as fear of public speaking), not for chronic anxiety disorders 3, 4
Even for performance anxiety, typical dosing would be propranolol 20-40 mg taken once before the specific event, not as ongoing treatment 4
This represents situational use for somatic symptoms (tremor, tachycardia) rather than treatment of an anxiety disorder 4, 5
What Should Be Used Instead
First-Line Treatment for Anxiety Disorders
SSRIs (escitalopram, sertraline) or SNRIs (venlafaxine, duloxetine) are the evidence-based first-line pharmacotherapy for generalized anxiety disorder, social anxiety disorder, panic disorder, and separation anxiety disorder 1, 3
Escitalopram and sertraline are specifically identified as top-tier first-line agents 3, 6
Response begins at week 2, becomes clinically significant by week 6, and reaches maximum benefit by week 12 3, 6
Cognitive behavioral therapy (CBT) combined with SSRIs/SNRIs provides superior outcomes to either treatment alone, with 12-20 structured sessions recommended 1, 3, 6
For Acute Anxiety Relief While Awaiting SSRI/SNRI Effect
Benzodiazepines (alprazolam, bromazepam, clonazepam) are recommended as second-line agents for rapid anxiety relief when first-line SSRIs/SNRIs have failed or during the initial 2-6 weeks while waiting for SSRIs/SNRIs to take effect 1, 3
Benzodiazepines should not be used for routine long-term anxiety management due to risks of dependence, tolerance, and withdrawal 3, 7
They are reserved for: acute stress reactions, episodic anxiety requiring rapid relief, and bridging therapy during SSRI/SNRI initiation 3, 7
Post-Acute Withdrawal Syndrome (PAWS)
Lack of Evidence for Propranolol
There is no published evidence supporting propranolol use for PAWS in the provided guidelines or research 1
The intensive care literature addresses acute alcohol withdrawal syndrome (AWS) but does not support propranolol for this indication either 1
Evidence-Based Approach to Withdrawal-Related Anxiety
For alcohol withdrawal specifically, benzodiazepines remain the mainstay when pharmacological intervention is required (approximately 20% of patients with AWS) 1
Benzodiazepine-sparing protocols using alpha-2 agonists (dexmedetomidine, clonidine) or anticonvulsants (gabapentin, carbamazepine, valproic acid) are being evaluated but require larger studies 1
For anxiety symptoms persisting after acute withdrawal (PAWS), the same first-line approach applies: SSRIs/SNRIs combined with CBT 3, 6, 8
Critical Pitfalls to Avoid
Do not prescribe propranolol for chronic anxiety disorders based on outdated practice patterns or anecdotal experience—the evidence is negative 1, 3, 2
Do not use antipsychotics (quetiapine) for anxiety disorders—they also have negative evidence for social anxiety disorder 1, 3
Do not combine benzodiazepines with opioids due to risk of fatal respiratory depression; if both are prescribed, taper opioids first 3
Do not discontinue SSRIs/SNRIs abruptly—taper gradually to avoid withdrawal symptoms, particularly with shorter half-life agents like paroxetine, fluvoxamine, and sertraline 1, 6
Do not abandon SSRI/SNRI treatment before 12 weeks—full therapeutic response requires patience due to the logarithmic response curve 3, 6
The Bottom Line
Despite increasing prescriptions of beta-blockers for anxiety between 2003-2018, there is a lack of robust evidence of effectiveness and explicit guideline recommendations against their use 2. The evidence-based approach is SSRIs/SNRIs as first-line pharmacotherapy combined with structured CBT, with benzodiazepines reserved only for acute situations or bridging therapy 1, 3, 6. For PAWS specifically, no role for propranolol has been established, and the same anxiety disorder treatment principles apply 3, 6, 8.