Clinical Overview
Propranolol is a non-selective beta-blocker with extensive psychiatric applications including performance anxiety, akathisia, aggressive behavior, and tremor. While primarily a cardiovascular medication, it has important uses in psychiatry due to its ability to block the peripheral manifestations of anxiety and its effects on the central nervous system.
Primary Clinical Applications
In psychiatry, propranolol is used for performance anxiety (stage fright), drug-induced akathisia, lithium-induced tremor, aggressive behavior, and sometimes as adjunctive treatment for PTSD. It is particularly effective for the physical symptoms of anxiety such as tremor, palpitations, and sweating.
Mechanism and Clinical Benefits
Propranolol blocks both beta-1 and beta-2 adrenergic receptors, reducing heart rate, blood pressure, and the peripheral manifestations of anxiety. It also crosses the blood-brain barrier and may have central effects on memory consolidation and fear conditioning, which may explain its utility in PTSD and performance anxiety.
Clinical Considerations
Propranolol is generally well-tolerated for psychiatric uses, which often involve lower doses and intermittent use compared to cardiovascular indications. However, it can cause fatigue, depression, and sexual dysfunction. It should be used cautiously in patients with asthma, diabetes, or certain cardiac conditions. Abrupt discontinuation should be avoided due to rebound hypertension risk.
Prescribing Information
Dosing & Administration
Performance Anxiety:
- Dose: 10-40 mg taken 30-60 minutes before performance
- Range: 10-80 mg as single dose
- Timing: 1 hour before anticipated anxiety-provoking situation
Akathisia:
- Initial: 10-20 mg twice daily
- Range: 20-80 mg daily in divided doses
- Titration: Increase gradually based on response
Lithium-Induced Tremor:
- Initial: 10-20 mg twice daily
- Range: 20-160 mg daily in divided doses
- Adjust based on tremor control
Aggressive Behavior:
- Initial: 20-40 mg twice daily
- Range: 80-320 mg daily in divided doses
- Higher doses may be needed for behavioral control
Administration:
- Take with food to improve absorption
- Divide daily dose into 2-3 administrations
- Extended-release: Once or twice daily
- Do not abruptly discontinue
Indications
- Psychiatric uses: Performance anxiety, akathisia, lithium tremor, aggressive behavior
- Primary indications: Hypertension, angina, arrhythmias, migraine prophylaxis
Contraindications
- Sinus bradycardia, heart block greater than first degree
- Cardiogenic shock, uncompensated heart failure
- Bronchial asthma, severe COPD
- Hypersensitivity to propranolol
Warnings & Precautions
- Abrupt withdrawal: May cause rebound hypertension, angina, MI
- Bronchospasm: Risk in patients with reactive airway disease
- Masking of hypoglycemia: May mask symptoms in diabetic patients
- Depression: May worsen or precipitate depression
- Fatigue: Common side effect that may affect function
- Peripheral vascular disease: May worsen symptoms
Drug Interactions
- Calcium channel blockers: Additive cardiac depression
- Insulin/oral hypoglycemics: May mask hypoglycemia symptoms
- CYP2D6 inhibitors: Increase propranolol levels
- Aluminum hydroxide: Reduces propranolol absorption
Adverse Reactions
Common (>5%):
- Fatigue, dizziness, bradycardia, hypotension
- Cold extremities, nausea, diarrhea
Psychiatric:
- Depression, sleep disturbances, vivid dreams
- Memory impairment, confusion (rare)
Sexual:
- Decreased libido, erectile dysfunction
Special Populations
- Asthma/COPD: Contraindicated due to bronchospasm risk
- Diabetes: May mask hypoglycemia symptoms
- Elderly: Start with lower doses, monitor for hypotension
- Pregnancy: Category C – use only if benefits outweigh risks
- Performance anxiety: Single doses generally well-tolerated
Medical Disclaimer: This information is for educational purposes only and is not intended as medical advice. Always consult with qualified healthcare professionals before making any treatment decisions. Individual patient circumstances may vary significantly.
