Propranolol is A tier for performance anxiety, taken an hour before the event to blunt the body's autonomic response, but only C tier for generalized anxiety. It is low risk and effective for akathisia and useful in trauma disorders when the fight-or-flight system is clearly revved up. Avoid it in asthma, watch the heart, and keep in mind the old worry that long-term beta blockers are depressogenic.
When we reach for it
We rank beta blockers A tier for performance anxiety, and probably C tier for generalized anxiety.
“For performance anxiety, A tier. For generalized anxiety, Probably B or C. Probably C tier”
48:52Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 For anxiety, look for evidence that the fight-or-flight system is upregulated before using it. We do use it for trauma disorders, and certainly for akathisia, because it is low risk and effective.
“I want to see some kind of evidence of upregulation of the fight or flight system. So I do use it for trauma disorders, and I certainly use it for echithesia because it's low risk and effective. I'm not opposed to using it if anyone wants to try it”
32:23Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025
Dosing and titration
For performance anxiety, 20 to 40 mg about an hour before the performance or other anxiety-provoking situation. It suppresses the autonomic response.
“I'll typically use like 20 to 40 milligrams of propranolol, tell the patient to use it an hour before the performance or whatever the anxiety provoking situation is. And what it tends to do is it just really suppresses that autonomic response”
33:33Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025 For akathisia over the long term, propranolol twice a day is preferred, and it can work from as little as 10 mg twice a day. If the akathisia is mild, restless-legs-like and only at night, nighttime gabapentin can be quite effective instead.
“Long term, I do prefer to put people on propranolol. twice a day. You can get effect from as little as 10 milligrams twice a day for akathisia. If the akathisia is more like a restless legs thing that's mild and only at night, gabapentin can be quite effective, nighttime gabapentin”
Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025
Side effects and safety
Do not use it in asthma, and be careful of the cardiac effects. In patients with comorbid migraine it can help a little.
“Don't use it in asthma. Do use it But for people. People who have comorbid migraine disorder. It can help a little bit with, yeah, consider it and be careful of the cardiac effects, of course”
50:24Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 Beta blockers were historically viewed as depressogenic. One study suggested propranolol may not be, but we still think of long-term beta blocker use as depressogenic.
“beta blockers historically were viewed as depressogenic. So to me, it doesn't, I think there was a study that showed that propranolol didn't hit that, but I still think of most beta blockers Use long term as the. Depressogenic”
51:24Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026
Talking to patients
Explain that it treats the perception of physical arousal as a threat. If you can learn to read that arousal as non-threatening, or even as excitement, you can modulate your body's response yourself, but that takes practice, not one night.
“it's essentially treating the perception of physiological arousal as a threat. If you can perceive physiological arousal as non-threatening, relatively speaking, or even as excitement instead, you will be able to modulate your body response. It's not something you can do overnight”
34:59Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025
It also comes up on
- AnxietyWhen the picture is likely trauma or personality and the diagnosis is still undifferentiated, start with smaller things (gabapentin, hydroxyzine, buspirone, propranolol) rather than serotonin-based medications, because of the risk of agitating an unrecognized bipolar disorder.
- Borderline personality disorderWhen the picture is likely trauma or personality and the diagnosis is undifferentiated, start with smaller things such as gabapentin, hydroxyzine, buspirone or propranolol, not serotonergic drugs, because of the risk of agitating a bipolar disorder.
- PTSDWhen the picture is likely trauma or personality and still undifferentiated, start with smaller things like gabapentin, hydroxyzine, buspirone or propranolol rather than serotonin-based drugs, because of the risk of agitating an unrecognized bipolar disorder.
From these episodes
- Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 · 3 points
- Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025 · 3 points
- Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.