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Am Fam Physician. 2005;72(5):758-761

to the editor: Nearly two full years after the events of September 11, 2001, I was consulted at a rural community mental health center on a 38-year-old male former emergency relief worker who was present for the cleanup after the collapse of the Twin Towers in New York City. He continued to experience severe sleep disturbance despite multiple medication trials including a selective serotonin reuptake inhibitor (SSRI), a mood stabilizer, and an atypical antipsychotic. Many of his other symptoms of posttraumatic stress disorder (PTSD), including “wild nightmares,” irritability, and reexperiencing scents and colors, had waned over two years, during which he also had undergone therapy to include Eye Movement Desensitization Response (EMDR). Other than an exhausted appearance, he had a normal mental status examination.

As presented so clearly by Dr. Grinage in the American Family Physician article, “Diagnosis and Management of Posttraumatic Stress Disorder,”1 PTSD is a compelling disorder that can severely disrupt a person’s premorbid lifestyle with intrusive thoughts, nightmares, sleep disturbance, irritability, and a plethora of other potentially disabling effects. One report2 demonstrated relief of nightmares in two veterans who were being treated with prazosin (Minipress) for benign prostatic hypertrophy. Subsequently, this was repeated successfully for five civilian trauma victims in another study3 and replicated in a placebo-controlled trial4 in 10 additional veterans. As noted by Raskind and colleagues,2 prazosin is a centrally active alpha1-adrenergic antagonist that should reduce excessive brain noradrenergic activity. The use of prazosin is likely to be familiar to family physicians given its past popularity in the treatment of patients with hypertension.

After warning the patient about the potentially significant first-dose effect of orthostatic hypotension, a trial of prazosin was initiated at 1 mg before bedtime. At follow-up, he reported excellent sleep, with no nightmares since the third week of the trial. He had experienced one minor spell of lightheadedness and some mild morning grogginess. He appeared well rested and in good condition. No dose escalation was required.

Prazosin should be considered in the treatment of the otherwise healthy patient with PTSD, if other standard treatments such as cognitive therapy and SSRIs have failed to relieve the sleep disturbance.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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