Is propranolol (beta-blocker) effective for treating anxiety disorders, particularly performance anxiety or social anxiety, in patients with or without pre-existing medical conditions such as asthma, diabetes, or heart failure?

Propranolol for Anxiety: Clinical Recommendations

Propranolol is effective for situational performance anxiety and acute stage fright at doses of 20-40 mg taken 1 hour before the event, but it is NOT recommended for chronic anxiety disorders like generalized anxiety disorder, panic disorder, or chronic social anxiety disorder, where SSRIs/SNRIs are first-line. 1, 2

When to Use Propranolol

Appropriate Indications

• Performance anxiety (stage fright, public speaking, test-taking): Take a single dose of 20-40 mg one hour before the event for acute situational use 1
• Anxiety with prominent physical symptoms: Propranolol reduces rapid heart rate, tremors, and nervousness by blocking peripheral adrenaline effects 1
• Procedural anxiety: Effective for surgeons experiencing tremor during procedures 1
• Adjunctive therapy: May provide symptomatic relief for residual somatic complaints (palpitations, tachycardia) when combined with ongoing treatment regimens 3

When NOT to Use Propranolol

• Generalized anxiety disorder: SSRIs (escitalopram, sertraline) or SNRIs (duloxetine, venlafaxine) are first-line, not propranolol 1, 4
• Chronic social anxiety disorder: Canadian and Japanese guidelines explicitly deprecate propranolol due to negative evidence; SSRIs/SNRIs are first-line 1, 2
• Panic disorder: Preliminary research shows propranolol is not encouraging for panic disorder 3
• Chronic or frequent performance anxiety: Use CBT as first-line, or SSRIs/SNRIs if pharmacotherapy is needed chronically 1

Critical Contraindications and Precautions

Absolute Contraindications

• Asthma or chronic obstructive pulmonary disease 1
• Bradycardia or heart block 1
• Decompensated heart failure 1
• Cardiogenic shock 1

Use With Caution

• Diabetes: Propranolol may mask hypoglycemia symptoms (tremor, tachycardia), making it harder to recognize low blood sugar 1
• Depression: Beta-blockers may induce or worsen depression in predisposed patients 3
• Abrupt discontinuation: Never stop propranolol suddenly after regular use, as this can cause rebound symptoms 1

Common Side Effects

• Bradycardia, hypotension, fatigue, cold extremities, and sleep disturbances 1
• Monitor heart rate and blood pressure, especially in patients with cardiovascular conditions 1

Practical Dosing Algorithm

For Situational Performance Anxiety

1. Screen for contraindications (asthma, heart block, heart failure, severe bradycardia) 1
2. Prescribe 20-40 mg propranolol to take 1 hour before the event 1
3. Advise a trial dose before an important event to assess individual response and tolerability 1
4. Do NOT use chronically for frequent performance anxiety; instead, refer for CBT or consider SSRIs/SNRIs 1

For Chronic Anxiety Disorders

1. Start with SSRIs (escitalopram 5-10 mg daily or sertraline 25-50 mg daily) as first-line 4
2. Titrate gradually over 1-2 weeks to therapeutic doses (escitalopram 10-20 mg, sertraline 50-200 mg) 4
3. Combine with CBT for optimal outcomes, as combination therapy is superior to either treatment alone 4
4. Reserve propranolol only for adjunctive management of residual physical symptoms if needed 3

Evidence Quality and Nuances

The evidence strongly supports propranolol for acute situational use but not for chronic anxiety disorders. 1, 2 While older studies from the 1970s-1990s suggested some benefit for anxiety with prominent somatic symptoms 5, 6, modern guidelines from 2023-2026 clearly state that SSRIs/SNRIs have superior evidence for chronic anxiety conditions 1, 4, 2.

Key pitfall: Do not prescribe propranolol for chronic daily use in generalized anxiety or social anxiety disorder, as this contradicts current guideline recommendations 1, 2. The role of propranolol is limited to acute, situational performance anxiety where a single dose provides symptomatic relief without the need for chronic therapy 1.