What are beta blockers commonly used for in psychiatry?
We use them a lot for both performance anxiety and social anxiety. They help more with the physical symptoms of anxiety. They don't directly help with rumination or worry. Now, if you have someone who has a lot of physical symptoms of anxiety – racing heart, feelings of a pounding chest, tremor – and that leads to worries, it can help indirectly by decreasing those physical symptoms and then not triggering the worry.
What are the differences between performance and social anxiety?
Performance anxiety would be public speaking, singing, musical instrument performing. Social anxiety would be people who get really anxious in social situations and then, because they're feeling so physically nervous, have trouble interacting with people. It’s fairly common for people to have both types of anxiety.
What are the benefits of beta blockers for anxiety over other prescription options?
It's nice because they don't have negative cognitive effects. Things like benzodiazepines –Ativan, Xanax, Valium – those can also be used for anxiety, but those also kind of slow down the brain and, at higher doses, make people feel high and out of it. Some people like the feeling, and so they can be addictive, both mentally and physically.
Beta blockers have no addictive potential, and they don't cause cognitive problems. I have no concern prescribing them unless someone has a physical contraindication. But, again, they don't directly help with the mental symptoms of anxiety. It's really just calming down the nervous system.
Could you expand on how the cognitive side-effect issue is important in performance and social anxiety?
If someone were to take Valium before giving a talk, they might have more trouble with word finding, or more trouble with being as sharp as they would want, versus if you take a beta blocker, it's not going to cause cognitive problems. Now, it can make people a little sleepy, but what I found is that if people have a lot of performance anxiety, they're going to be revved anyway. So, the amount of sleepiness they get from the beta blocker is probably not going to counteract the being revved. They may be a little bit more tired after the event is over.
How do beta blockers work in the body?
They work on what are called beta-adrenergic receptors. Those are receptors that respond to norepinephrine, also called adrenaline. The most common one we use in psychiatry is propranolol, and that's a non-selective beta blocker, so it works both on cardiac muscle and on skeletal muscle. And that's helpful, because on cardiac muscle it slows down the heart rate and on skeletal muscle, it helps with tremor. Some people do use selective beta blockers, so atenolol would be a selective beta blocker, but that would help more with the cardiac symptoms like the racing heart, pounding chest, but not as much with tremor. Non-selective types work with beta-1 and beta-2 receptors.
What are beta blockers’ common medical uses?
Beta blockers are mainly used to treat cardiovascular issues, such as:
- Aortic aneurysms
- Arrhythmias
- Chest pain
- Heart disease
- High blood pressure
Other conditions include:
- Glaucoma
- Hyperthyroidism
- Migraines
- Portal hypertension
- Tremors
- Performance anxiety
- Social anxiety
How fast do beta blockers work?
Usually within 20 to 30 minutes. I usually tell people to take it about 30 minutes before the situation.
Is that one of the attractions of beta blockers for anxiety – that they work quickly and can be taken only as needed?
Yes. But again, they aren't really so useful for the core symptoms of generalized anxiety or baseline anxiety. If someone really has generalized anxiety where they kind of worry all the time, they need something more – such as cognitive behavioral therapy and/or an SSRI (selective serotonin reuptake inhibitor), such as sertraline or fluoxetine, a daily medication to almost rewire the brain. As-needed use of propranolol doesn't cause the same sort of long-lasting changes in the brain, so it's not going to address a baseline or chronic mental health disorder.
Is professional talk therapy along with medications important for severe anxiety disorders?
Yes. And actually, therapy can be useful even for performance anxiety. With performance or social anxiety, we do a type of therapy called exposure therapy, where we actually work with people to practice being in the uncomfortable settings and learning to do the things even in the presence of anxiety. And then the more you do it, the more the physical response tones down. For example, I don't like public speaking, and I used to get really shaky and anxious, but now that I do it all the time as part of my job, I don't really get those symptoms as much anymore.
What other patient populations might you suggest beta blockers for?
I treat a lot of students, and I think even a lot of health professional students aren't necessarily aware that this is an option that can be super helpful. For example, if they’re on a surgery rotation, and they're having to do something intricate with all these people watching them, a beta blocker can be useful. Even for test anxiety, or for grad students who have to do a lot of public speaking and presenting of their research, it can be useful.
Could beta blockers serve as a temporary tool to help people overcome these fears and physical symptoms?
I think it absolutely can, because it helps you put yourself in the scary situations, and even that is practice, even if you're doing it with less of an adrenaline response, so absolutely.
When would you not prescribe beta blockers to a patient?
For people who have severe asthma or any sort of obstructive lung disease, the non-selective beta blockers can worsen that. And so, in someone who has severe asthma, I'd be more likely to use a selective beta blocker, because it works mainly on heart muscles and doesn’t have much effect on the smooth muscles in the lung.
If I have someone who has a resting heart rate that's 50 or lower, again, beta blockers probably aren't the best, because they do slow your heart rate. Also, if I have someone who's really sensitive to low blood pressure and has a history of passing out because of low blood pressure, then I would also be careful about using a beta blocker.
Other contraindications include some severe cardiac issues and insulin-dependent diabetes (because they blunt the body’s response to low blood sugar, which could keep someone from being aware of a dangerous situation).
Key points:
- Beta blockers help reduce physical symptoms of anxiety, such as rapid heartbeat and trembling.
- They are commonly used for performance anxiety and some forms of social anxiety.
- Most people feel effects within 20 to 30 minutes.
- Beta blockers are generally non-addictive and do not impair thinking the way some anxiety medications can.
- They are not considered effective treatment for generalized anxiety disorder.
- They should only be used with a prescription and under medical supervision.
