Beta Blockers in Anxiety Disorder

[SCPA]

Classically Propranolol,  which I've had a lot of success with in the right patient. Does anyone have experience using the B1 selective BBs? In theory these  should work just as well right? 

Gracias! 

[Reality Check 2]

I have only ever used propranolol in solo anxiety as well as tremor. I have used metoprolol in combo anxiety and HTN and given it at night to help with sleep. Bradycardia has become a problem in some folks, particularly women.

Not good with asthma/COPD patients in a lot of cases due to wheezing.

Using more hydroxyzine but the somnolence isn't working in the daytime.

Trying to avoid benzos altogether but it gets tough.

SSRIs like lexapro are still my go to. Paxil and Zoloft have too much weight gain and withdrawal. Some success with Effexor but a lot of complaints about sweating - especially men.

Behavioral Mod therapy is still an absolute must if anything is to work.

[d2305]

Clonidine is effective in some patients.

[sk732]

I had a guy that I inherited on po timolol for their anxiety - he swore by it.  I know of people that don't like public speaking much or have big exams (medical boards and such) or interviews that ask for some propranolol or similar agents to keep them on an even keel.  As RC2 notes, should probably use a Beta1 selective instead of the older nonselectives, as you can get a lot of unwanted bronchospasm and such in asthmatics...a family doc stuck an ex-gf of mine on propranolol for her HTN without thinking she was a brittle asthmatic - used to get woken up A LOT from early am decompensations until I not so subtly suggested an ACEI instead.

Now I'm in EM, I don't think much of using them for anything other than a new Dx of essential tremor if it's causing grief, though I really ought to rethink it for the chronically anxious folks showing up in the ER for chronically anxious reasons (and trying to score chronically anxious refills).

SK

[DizzyJ]

when I did outpatient psych we only used propranolol when choosing a BB. 

[lemurcatta]

I see a lot of clinicians online say they try to avoid benzodiazepines at all costs. I'm not a PA yet, but I am a paramedic with a lot of experience and also have personal knowledge in this area. In the right patient, merely the knowledge that they have a small amount of PRN lorezepam or whatever available in their bag/purse is a huge help in GAD and panic disorder. Having the meds in the bag is therapeutic in and of itself. For this to work they should be counseled not to rely on benzos daily, and only given enough for that crutch. But my personal plea to you as clinicians is not to avoid them entirely. I've seen them help people close to me without dependence. I've seen this in my own patients as well- I have a special interest in psych. 

[SCPA]

5 hours ago, dizzyjon said:

when I did outpatient psych we only used propranolol when choosing a BB. 

I wonder if this is just for tradition's sake or if there's a good reason.. 

[DizzyJ]

2 hours ago, lemurcatta said:

I see a lot of clinicians online say they try to avoid benzodiazepines at all costs. I'm not a PA yet, but I am a paramedic with a lot of experience and also have personal knowledge in this area. In the right patient, merely the knowledge that they have a small amount of PRN lorezepam or whatever available in their bag/purse is a huge help in GAD and panic disorder. Having the meds in the bag is therapeutic in and of itself. For this to work they should be counseled not to rely on benzos daily, and only given enough for that crutch. But my personal plea to you as clinicians is not to avoid them entirely. I've seen them help people close to me without dependence. I've seen this in my own patients as well- I have a special interest in psych. 

Agree that there is use for them.  I had many patients who simply needed to know they had a pill available if they needed it.  If you need a benzo once or twice a month, no problem.  

[Cideous]

As someone with HTN and situational anxiety I can tell you I love Metoprolol.  It works great for me as a 48 year old white male, and really helps keep my heart rate in check when I become anxious.  I get the occasional postural hypotension, but for the most part symptoms free.  Just remember that it is not a mood stabilizer, obviously, so it's not going to bring you back to the middle like an SSRI, but it will keep your heart from racing during anxiety incidents.  Anxiety attacks are often times stacking.  Heart rate increases, breathing becomes shallow and your mind goes to that dark place of "I think I am dying".  The Beta blocker is fantastic at cutting off those symptoms before they stack up too high.

[Lexapro]

One psychiatrist I worked with stated she prefers propranolol for anxiety over other BBs because of the ease with which it crosses the blood-brain barrier. However, I do not understand how penetration of the blood-brain barrier makes propranolol more efficacious for anxiety, wouldn't it just mean that the patient is more likely to experience CNS effects such as nightmares and sleep disturbance? From what I understand, the benefit for BBs for anxiety is all cardiac (lowering HR, improving chest discomfort) and possibly improving tremor.

[ruralem]

I just used propranolol in an acutely anxious patient in the ED.  Has multiple visits in last 3 weeks, hx of drug abuse, and I wanted to avoid benzos.  used 20 mg PO and he felt much improved after 45 minutes.  HR came down into 90's from 120's.  Symptoms resolved.  I'm a believer.

[SCPA]

On 9/2/2017 at 3:10 PM, Lexapro said:

One psychiatrist I worked with stated she prefers propranolol for anxiety over other BBs because of the ease with which it crosses the blood-brain barrier. However, I do not understand how penetration of the blood-brain barrier makes propranolol more efficacious for anxiety, wouldn't it just mean that the patient is more likely to experience CNS effects such as nightmares and sleep disturbance? From what I understand, the benefit for BBs for anxiety is all cardiac (lowering HR, improving chest discomfort) and possibly improving tremor.

This is where I scratch my head too...