World Health Organisation (WHO) defines anxiety disorders as a group of mental conditions characterised by a feeling of fear and anxiety (WHO, 2017). Some common forms of anxiety include generalised anxiety disorder (GAD), social anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. Treatment options for (general) anxiety disorder include psychological interventions and drug treatment. can you use beta blockers for anxiety? In this post, I will discuss the use of propranolol for anxiety, the only beta blocker used for anxiety in the UK.
What is anxiety?
Anxiety is a normal and natural human emotion that everyone experiences from time to time. It is the feeling of unease, worry, or fear that can be triggered by a variety of situations, such as facing a new or challenging task, meeting new people, or worrying about a future event.
However, when anxiety becomes excessive, overwhelming, and persistent, it can interfere with daily life and be classified as an anxiety disorder. Anxiety disorders are a group of mental health conditions that are characterized by intense and prolonged feelings of anxiety and fear, even in the absence of an actual threat or danger. These disorders can include generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobias, among others.
Anxiety symptoms can vary depending on the individual and the type of anxiety disorder, but common symptoms include:
- persistent worry
- difficulty concentrating
- muscle tension, and
- sleep disturbances (insomnia).
It is important to seek professional help if anxiety symptoms are interfering with your daily life or causing significant distress.
Anxiety – treatment options
Pharmacological management of GAD involves the use of antidepressants, such as a selective serotonin reuptake inhibitor (SSRI) or a serotonin–noradrenaline reuptake inhibitor (SNRI). Sertraline is usually recommended when SSRIs are considered in the treatment of anxiety because it offers the most cost-effective treatment (NICE, 2021).
NICE guideline on the management of generalised anxiety disorder and panic disorder in adults does not mention the use of beta-blockers, although it is known that beta-blockers may elevate the symptoms of anxiety.
A short course (3-7 days) of a non-benzodiazepine hypnotic medication (z-drug), such as zopiclone or zopiclone alternative drugs for sleeping may be prescribed for short-term management of insomnia where sleep hygiene measures fail and the patient experiences significant distress.
What are beta-blockers?
Beta-blockers are a class of medication used to treat various medical conditions, primarily cardiovascular disorders such as hypertension (high blood pressure), angina (chest pain), and heart failure. Beta-blockers can also be used to treat anxiety disorders, migraines, and tremors.
Beta-blockers work by blocking the effects of the hormone adrenaline (also known as epinephrine) on the beta receptors in the body, which leads to a decrease in heart rate and blood pressure.
There are several types of beta blockers, including selective and non-selective beta blockers. Selective beta-blockers (for example, propranolol) target only the beta-1 receptors in the heart, while non-selective beta-blockers (for example, bisoprolol, atenolol) block both the beta-1 and beta-2 receptors throughout the body.
Selectivity, therefore, relates to the ability of beta-blockers to work in specific regions of the body. Beta-1 receptors are predominantly located in the heart, whereas beta-2 receptors are distributed throughout the body. Non-selective beta-blockers bind to both beta-1 and beta-2 receptors, whereas selective beta-blockers mainly to beta-1 receptors and are commonly known as ‘cardio-selective.’
Propranolol for anxiety – how does it help with the symptoms?
Beta-blockers can be used to treat anxiety by blocking the physical symptoms of anxiety, such as an elevated heart rate, trembling, and sweating. These symptoms are caused by the release of adrenaline (also known as epinephrine) in response to stress or anxiety. Adrenaline is responsible for the ‘fight or flight’ response characterised by an increase in the heart rate and tremor also associated with symptoms of anxiety.
By blocking the beta receptors in the body, beta-blockers can reduce the effects of adrenaline, which leads to a decrease in heart rate and blood pressure, as well as a decrease in physical symptoms of anxiety. This can help individuals with anxiety to feel calmer and more relaxed.
It’s important to note that beta blockers are not typically used as a first-line treatment for anxiety disorders, as they primarily address the physical symptoms of anxiety rather than the underlying psychological causes. They are generally used in conjunction with other therapies, such as cognitive-behavioural therapy or medication specifically designed to treat anxiety disorders.
Propranolol for performance anxiety
Similarly to anxiety disorders, beta-blockers can be used to control symptoms of performance anxiety, such as performing in public or in front of others. People who experience stage fright may comfort similar to panic disorder symptoms such as tremors, increased heartbeats/palpitations, and sweating affecting their performance (Bourgeois, 1991).
By blocking physiological signs of anxiety, beta-blockers create a positive feedback loop, and as a result, patients become less conscious of being anxious (ibid).
Why is propranolol used for anxiety?
Propranolol is a non-selective beta-blocker and the only beta-blocker used in the management of anxiety in the UK. Propranolol is a prescription-only medication, which means it can only be obtained on a prescription written by a qualified prescriber.
In relation to anxiety, propranolol is licensed in the management of:
- Anxiety tachycardia (fast heartbeat due to anxiety)
- Anxiety with symptoms such as palpitation, sweating, and tremor
Dose of propranolol for anxiety
The recommended daily dose of propranolol in the management of anxiety is 40mg once daily. If necessary, this dose can be increased up to 40mg 3 times a day (BNF, 2023).
Propranolol is available as 10mg, 40mg, and 80mg tablets, as well as 80mg and 160mg, sustained-release capsules.
Propranolol sustained release (also called modified release) is taken daily as compared to standard tablets, which can be taken up to three times a day. When sustained-release capsules are used for the management of situational and generalised anxiety, a daily dose of 80mg of propranolol should be adequate to provide short-term relief of acute situational anxiety (EMC, 2020).
Long-term management of generalised anxiety can be managed with the same dose, or if necessary, the dose can be increased to 160mg of sustained-release propranolol.
Propranolol for anxiety: possible side effects
The use of beta-blockers, such as propranolol, is associated with several possible side effects. Common side effects include:
- Sleep disturbances, nightmares
- Slow heart rate
- Cold extremities (fingers or toes)
- Fatigue, feeling tired.
- Nausea (feeling sick)
- Erectile dysfunction
Some side effects, such as dizziness, may go away after a few days once the body gets used to the treatment. For less common side effects, please refer to propranolol’s product information leaflet.
Effectiveness of propranolol for anxiety
Systemic review and meta-analysis (review of all available evidence) do not give definite conclusions in favour or against the use of propranolol in the treatment of anxiety disorders. The main reason is the lack of well-designed clinical trials to show the efficacy of propanol in the management of anxiety (Steenen, et al 2015). Despite the lack of strong evidence, beta-blockers can provide some symptomatic relief of anxiety, including performance anxiety.
Who should not take propranolol for anxiety?
Beta-blockers are generally safe and well-tolerated, but some individuals should not use beta-blockers or should use them only under close medical supervision. These include:
Individuals with asthma or other respiratory conditions: Beta blockers can cause bronchospasm and breathing difficulties in individuals with asthma or other respiratory conditions.
Individuals with certain heart conditions: Beta blockers can worsen heart failure in individuals with severe heart failure, and can also cause bradycardia (a slow heart rate) in individuals with certain types of heart block.
Individuals with low blood pressure: Beta blockers can cause a further drop in blood pressure, which can lead to dizziness and fainting in individuals with low blood pressure.
Individuals with diabetes: Beta blockers can mask some of the symptoms of hypoglycemia (low blood sugar), which can make it more difficult for individuals with diabetes to manage their blood sugar levels.
Individuals taking certain medications: Beta blockers can interact with other medications, including calcium channel blockers, digoxin, and certain antidepressants.
It’s important to talk to your GP before using beta blockers and to inform the doctor of any medical conditions or medications that you are currently taking. A doctor can help determine whether beta blockers are safe and appropriate for you to use.
Beta-blockers for anxiety: conclusion
Evidence-based recommendations on the management of anxiety recommend a selective serotonin reuptake inhibitor (SSRI) as the first-line drug treatment for this condition. In the UK, the only beta-blocker recommended for the management of anxiety is propranolol. Patients experiencing physical symptoms of anxiety, such as rapid heart rate and tremor, may benefit from the treatment with beta-blockers.
BNF (2023). Propanolol hydrochloride. Available at: https://bnf.nice.org.uk/drugs/propranolol-hydrochloride/ Accessed on 24/02/2023
Bourgeois James A. (1991). The Management of Performance Anxiety with Beta-Adrenergic Blocking Agents. Available at: https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1284&context=jeffjpsychiatry Accessed on 24/02/2023
EMC (2020). SmPC: Bet- Prograne 160mg Sustained-Release Capsules. Available at: https://www.medicines.org.uk/emc/product/11217/smpc Accessed on 24/02/2023
NICE (2020). Hypnotics and anxiolytics. Available at: https://bnf.nice.org.uk/treatment-summary/hypnotics-and-anxiolytics.html Accessed on 24/02/2023
NICE (2021). Generalised anxiety disorder and panic disorder in adults: management. Available at https://www.nice.org.uk/guidance/cg113/chapter/Recommendations Accessed on 24/02/2023
WHO (2017). Depression and Other Common Mental Disorders. Available at: https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf Accessed on 24/02/2023