In a 20‑year‑old patient receiving quetiapine 25 mg twice daily for mild hallucinations and anxiety who is experiencing anger outbursts and persistent anxiety, can I add propranolol 10 mg twice daily?

Adding Propranolol to Quetiapine for Anger and Anxiety

I would not add propranolol 10 mg BID to this patient's regimen, as propranolol can cause or worsen psychiatric symptoms including hallucinations, psychosis, and depression—particularly problematic in a young patient already experiencing hallucinations on quetiapine.

Primary Concern: Propranolol's Psychiatric Risks

The evidence strongly suggests propranolol carries significant psychiatric risks that are especially concerning in your clinical scenario:

• Propranolol can induce psychosis, hallucinations, and severe depression even at recommended dosages, with symptoms developing shortly after initiation 1, 2
• A 21-year-old male developed hallucinations, personality changes, and severe depression with suicidal impulses on standard propranolol doses, requiring drug discontinuation 1
• Psychiatric side effects from propranolol include paranoid ideations, visual hallucinations, severe combativeness, and illusions 2, 3
• These central nervous system effects occur due to propranolol's lipophilic properties allowing significant CNS penetration 3

Your Patient's Specific Vulnerabilities

Your 20-year-old patient is particularly at risk because:

• Already experiencing mild hallucinations on quetiapine 25 mg BID—adding propranolol could exacerbate these perceptual disturbances 1, 2
• Young age matches the demographic in reported propranolol-induced psychosis cases 1
• The combination of quetiapine (which itself can rarely cause paradoxical psychotic symptoms) with propranolol creates compounded risk 4

Alternative Management Strategy

Instead of adding propranolol, consider this approach:

First-Line: Optimize Current Antipsychotic

• Increase quetiapine dose gradually from 25 mg BID, as quetiapine is effective for both positive symptoms (hallucinations) and hostility/aggression at therapeutic doses 5
• Quetiapine demonstrates efficacy in reducing hostility, aggression, and affective symptoms with minimal extrapyramidal side effects 5
• The current 50 mg/day total dose is subtherapeutic; typical effective doses range 150-750 mg/day for psychotic symptoms 6

If Inadequate Response to Quetiapine Optimization

• Consider switching to a different atypical antipsychotic rather than adding propranolol 6
• Options include olanzapine 2.5-5 mg daily (effective for agitation), risperidone 0.5 mg (though higher EPS risk), or aripiprazole 5 mg daily (lower EPS profile) 6

For Acute Agitation Episodes

• Short-term benzodiazepines PRN (lorazepam 0.5-1 mg) may be appropriate for breakthrough anger outbursts, though use cautiously given risk of paradoxical agitation 6, 7
• These should be used sparingly and not as standing doses in young patients 6

Critical Pitfall to Avoid

Do not assume propranolol is "just for anxiety" in psychiatric patients—its CNS effects can destabilize fragile psychiatric presentations, particularly in patients with existing perceptual disturbances 1, 2, 3. The risk-benefit ratio strongly favors optimizing the existing antipsychotic regimen rather than introducing a beta-blocker with known psychotomimetic potential.