Propranolol is a beta-blocker typically used for hypertension, tremor, and performance anxiety. Research has shown that it can also disrupt memory reconsolidation, allowing individuals to potentially disarticulate their worst fears or memories from the negative emotions and physiological distress that usually accompany them.[1]
Research on the memory reconsolidation process has shown that when we think about a frightening event (past or anticipated), the proteins associated with that thought or memory in our brains destabilize and become susceptible to change.[2] This destabilization process is referred to as opening the memory reconsolidation window. Giving a dose of propranolol (or having it available in the bloodstream) as soon as this window opens appears to be a critical component of the successful use of this medication to resolve phobias and PTSD.
Single-Dose Propranolol Given at the Moment of Peak Distress
Evidence suggests that a single dose of propranolol, given at a specific point in time, can be extremely powerful in treating conditions associated with high physiological arousal, such as phobias and PTSD. This series of engaging YouTube videos follows one of the world’s leading researchers of this technique, Dr. Merel Kindt of Amsterdam:
- A Cure for Fear: A Little Closer
- A Cure for Fear: Nighttime in Kabul
- A Cure for Fear: You Did Your Very Best
- A Cure for Fear: Self Treatment
Dr. Kindt is currently reporting remission rates of around 85% in her clinical practice.
Kindt’s protocol for adults and adult-sized teens[3]
- Expose the patient to a feared situation or memory until they are at the point of maximum fear, terror, or distress, as indicated by a score of 100 on a 100-point Subjective Units of Distress (SUDS) scale.
- Emphasize to the patient that their worst predicted fear has not happened, i.e. they are still alive, they did not pass out, they did not go crazy, they did not cry, etc. (this establishes an important prediction error)
- Remove the patient from the exposure process.
- Immediately give the patient 40 mg of immediate-release propranolol by mouth.
- Release the patient from the intervention and tell them to go rest.
Propranolol as Pre-Treatment before Therapy Sessions
Another use of propranolol that has been researched is pre-treating patients with propranolol just before a trauma-focused psychotherapy session. Dr. Alain Brunet in Montreal is a leading proponent of this technique. His protocol involves giving a combination of short and long-acting propranolol 60 minutes before the trauma therapy intervention.[4] The use of long-acting propranolol has been hypothesized by some to blunt the physiological activation necessary to open the memory reconsolidation window, so it may not be as effective as Kindt’s method.
NOTE: Propranolol is not recommended in patients with any of the following:[5]
Resting Systolic Blood Pressure < 90 mm Hg
Resting Diastolic Blood Pressure < 60 mm Hg
Resting Heart Rate < 55 bpm
Reactive Airway Disease, e.g. Asthma
Cardiac Arrhythmia, e.g. Atrial Fibrillation, etc.
Congestive Heart Failure
Liver Disease
Kidney Disease
Diabetes
Pregnancy
Taking an anti-arrhythmic medication
Taking a calcium channel blocker
Bibliography
[1] Kindt M, Soeter M, Vervliet B. Beyond extinction: erasing human fear responses and preventing the return of fear. Nat Neurosci. 2009 Mar;12(3):256-8. doi: 10.1038/nn.2271.
[2] Duvarci S, Nader K. Characterization of fear memory reconsolidation. J Neurosci. 2004 Oct 20;24(42):9269-75. doi: 10.1523/JNEUROSCI.2971-04.2004.
[3] Kindt M, van Emmerik A. New avenues for treating emotional memory disorders: towards a reconsolidation intervention for posttraumatic stress disorder. Ther Adv Psychopharmacol. 2016 Aug;6(4):283-95. doi: 10.1177/2045125316644541.
[4] Brunet A, et al. Reduction of PTSD Symptoms With Pre-Reactivation Propranolol Therapy: A Randomized Controlled Trial. Am J Psychiatry 2018;175:427-33; doi: 10.1176/appi.ajp.2017.17050481
[5] Supplementary Text and Figures from Kindt’s 2009 Nature Neuroscience article. Accessed March 5, 2024, at https://static-content.springer.com/esm/art%3A10.1038%2Fnn.2271/MediaObjects/41593_2009_BFnn2271_MOESM17_ESM.pdf
Dr. Wendi Waits (she/her) is an adult and child psychiatrist, certified lifestyle medicine physician, and consultant at MH Insight, LLC. She has written numerous articles, book chapters, and scientific publications on medical leadership and various mental health topics, and she is an experienced public speaker. To see more of Wendi’s work, please visit MHInsight.com.