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Propranolol in performance anxiety — MRCPsych Paper A MCQ

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ModeratePsychopharmacologyPropranolol in performance anxietyMRCPsych Paper A

A 23-year-old medical student experiences marked anticipatory anxiety before observed clinical examinations. Propranolol taken before an examination substantially reduces palpitations and hand tremor, although their anxious thoughts remain. Which pharmacological action most directly accounts for the improvement in these physical symptoms?

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Correct answer: D — Antagonism at peripheral beta-1 and beta-2 adrenoceptors

The correct answer is D. Propranolol is a non-selective competitive antagonist at beta-1 and beta-2 adrenoceptors. Peripheral beta-1 blockade reduces cardiac adrenergic effects such as tachycardia and forceful heartbeat, while beta-2 blockade contributes to reducing adrenergic tremor. This explains why propranolol can improve the somatic manifestations of situational or performance anxiety while anticipatory worry may persist. Although propranolol is lipophilic and can enter the CNS, peripheral beta-adrenoceptor blockade most directly explains the response described. Dopamine D2 antagonism is characteristic of antipsychotics; muscarinic M1 antagonism produces anticholinergic effects; 5-HT2A antagonism occurs with several atypical antipsychotics and antidepressants; and NMDA antagonism is not propranolol's therapeutic mechanism.

Reference: Flamingo Pharma (UK) Ltd. Propranolol Hydrochloride 10 mg Film-coated tablets, Summary of Product Characteristics, sections 4.1 and 5.1. Updated 7 April 2026. https://www.medicines.org.uk/emc/product/100086/smpc