What beta blocker (beta-adrenergic blocking agent) is recommended for anxiety events?

Beta Blocker Recommendation for Anxiety Events

Beta-blockers are NOT recommended for chronic anxiety disorders, but propranolol 20-40 mg taken 1 hour before an event is the preferred beta-blocker for acute situational performance anxiety (stage fright). 1

Critical Guideline Position

The most recent international guidelines (2023) explicitly deprecate both atenolol and propranolol for chronic social anxiety disorder based on negative evidence. 2 The Canadian Clinical Practice Guidelines specifically recommend against these agents for generalized or chronic anxiety conditions. 2

When Beta-Blockers ARE Appropriate

For situational/performance anxiety only:

• Propranolol is the preferred agent for isolated, infrequent public speaking events or stage fright 1
• Dosing: 20-40 mg taken 1 hour before the anxiety-provoking event 1
• Critical caveat: Advise a trial dose before an important event to assess individual response and tolerability 1

Why Propranolol Over Other Beta-Blockers

• Propranolol is a non-selective beta-blocker that blocks peripheral adrenaline effects, reducing rapid heart rate, tremors, and nervousness 1
• It has established efficacy for essential tremor (up to 70% of patients) and performance anxiety 1
• While atenolol showed high patient satisfaction in one 2020 military study (86% positive effect), 3 this lacks the guideline support and rigorous evidence that propranolol has 4, 5, 6

Absolute Contraindications to Screen For

Before prescribing propranolol, you must exclude:

• Asthma or chronic obstructive pulmonary disease 1, 7
• Bradycardia or heart block 1
• Heart failure or decompensated systolic heart failure 1
• Severe hypotension or cardiogenic shock 1

Additional cautions:

• Diabetes (may mask hypoglycemia symptoms) 1, 7
• Do not abruptly discontinue after regular use (rebound symptoms) 1

What to Do for Chronic Anxiety Instead

If the patient has frequent or chronic anxiety (not just isolated events):

• First-line: Cognitive behavioral therapy (CBT) 1, 8
• First-line pharmacotherapy: SSRIs (escitalopram, sertraline) or SNRIs (venlafaxine) 2, 8
• Second-line: Benzodiazepines (alprazolam, bromazepam, clonazepam), pregabalin, or gabapentin 2, 8
• Beta-blockers have no role in chronic anxiety management 1

Clinical Algorithm

1. Determine anxiety pattern: Is this situational/performance anxiety OR chronic/generalized anxiety?
2. If situational: Screen for beta-blocker contraindications (asthma, heart block, bradycardia, heart failure)
3. If contraindications absent: Prescribe propranolol 20-40 mg to take 1 hour before event 1
4. Mandate trial dose: Patient must test medication before critical performance 1
5. If chronic anxiety: Refer for CBT and/or initiate SSRI/SNRI, NOT beta-blockers 1, 8

Common Pitfall to Avoid

The most significant error is prescribing beta-blockers for chronic daily anxiety. 1 This approach lacks evidence and delays appropriate treatment with SSRIs/SNRIs or CBT, which have demonstrated efficacy for long-term anxiety management. 2 Beta-blockers are strictly for acute, predictable, situational use only. 1