What is the best treatment approach for a patient with improved social anxiety on Propranolol, Sertraline, and Trazodone, but with reduced inhibitions, sleep disturbances, and decreased appetite?

Optimal Treatment Approach for a Patient with Improved Social Anxiety but Experiencing Side Effects

The best treatment approach for this patient is to maintain sertraline at 150mg daily, discontinue propranolol since social anxiety symptoms have resolved, and continue trazodone 100mg PRN for sleep, while monitoring for disinhibition effects that may be related to sertraline. 1, 2

Current Medication Assessment

Sertraline (150mg daily)

• Patient reports good overall mood and significant improvement in social anxiety symptoms
• Potential side effects observed:
  • Reduced inhibitions (wandering for 5 hours, missing flight)
  • Decreased appetite (though no weight loss)
  • These are known side effects of sertraline 2

Propranolol (10mg BID)

• Initially prescribed for social anxiety symptoms
• Social anxiety symptoms are now "virtually gone"
• Common side effects include sleep disturbances, which may be contributing to the patient's sleep issues 3
• No longer necessary as the target symptoms have resolved

Trazodone (100mg PRN for sleep)

• Providing adequate sleep when taken
• Sleep disturbances occur mainly when traveling for work
• 100mg is an appropriate dose for sleep disorders with depressive features 4

Recommended Treatment Plan

1. Sertraline Adjustment:

   • Maintain current dose of 150mg daily as it has effectively treated social anxiety
   • Monitor for disinhibition effects (missing flight, wandering)
   • If disinhibition persists, consider reducing dose to 100mg daily while monitoring for return of anxiety symptoms 1, 2

2. Propranolol Discontinuation:

   • Gradually taper and discontinue propranolol since social anxiety symptoms have resolved
   • Taper schedule: Reduce to 5mg BID for 1 week, then 5mg daily for 1 week, then discontinue
   • This will eliminate potential side effects of propranolol including sleep disturbances 3

3. Trazodone Management:

   • Continue trazodone 100mg PRN for sleep
   • Emphasize consistent sleep hygiene practices, especially when traveling
   • Consider scheduled (rather than PRN) dosing during travel periods 4

Monitoring Plan

• Follow up in 2-4 weeks to assess:

  • Social anxiety symptoms after propranolol discontinuation
  • Disinhibition effects potentially related to sertraline
  • Sleep quality, particularly during travel
  • Appetite and weight

• Use standardized assessment tools to track anxiety symptoms and treatment response 1

Potential Pitfalls and Considerations

• Sertraline side effects: The disinhibition (wandering, missing flight) is likely related to sertraline. If this behavior continues or worsens, dose reduction may be necessary 2

• Propranolol discontinuation: Monitor for potential rebound anxiety when discontinuing propranolol, though this is less likely since the patient's social anxiety is well-controlled with sertraline 3, 5

• Sleep management: If sleep disturbances persist after propranolol discontinuation, consider scheduled (rather than PRN) trazodone during travel periods 4

• Treatment duration: Maintenance therapy with sertraline should continue for 12-24 months after achieving remission to prevent relapse 1