Treatment of Nightmares With Prazosin: A Systematic Review

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN.
Mayo Clinic Proceedings (Impact Factor: 6.26). 08/2012; 87(9):890-900. DOI: 10.1016/j.mayocp.2012.05.015
Source: PubMed


Nightmares, frequently associated with posttraumatic stress disorder and clinically relevant in today's world of violence, are difficult to treat, with few pharmacologic options. We performed a systematic review to evaluate the evidence for the use of prazosin in the treatment of nightmares. A comprehensive search was performed using the databases EMBASE, Ovid MEDLINE, PubMed, Scopus, Web of Science, and Cochrane Database of Systematic Reviews, from their inception to March 9, 2012, using keywords prazosin and nightmares/PTSD or associated terms (see text). Two authors independently reviewed titles and abstracts and selected relevant studies. Descriptive data and outcomes of interest from eligible studies were extracted by 1 author, and checked by 2 others. The risk of bias of randomized controlled trials (RCTs) was assessed independently by 2 reviewers. Articles met criteria for inclusion if prazosin was used to treat nightmares, and outcome measures included nightmares or related symptoms of sleep disorders. Our search yielded 21 studies, consisting of 4 RCTs, 4 open-label studies, 4 retrospective chart reviews, and 9 single case reports. The prazosin dose ranged from 1 to 16 mg/d. Results were mixed for the 4 RCTs: 3 reported significant improvement in the number of nightmares, and 1 found no reduction in the number of nightmares. Reduced nightmare severity with use of prazosin was consistently reported in the open-label trials, retrospective chart reviews, and single case reports.

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    • "Pharmacologically , adrenergic modulating agents have demonstrated efficacy in reducing or ameliorating nighttime disturbances in adults with PTSD. Specifically, prazosin has demonstrated efficacy in the reduction of nighttime symptoms in multiple randomized control trials in adults (Kung et al. 2012) and in case reports in children (Strawn and Keeshin 2011). Other antiadrenergic agents commonly used in the pediatric population, such as guanfacine and clonidine, have demonstrated mixed results in the treatment of PTSD (Keeshin and Strawn 2014). "
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    ABSTRACT: Little is known regarding neuroendocrine responses in adolescent girls with posttraumatic stress disorder (PTSD) who have experienced sexual abuse. Therefore, we collected saliva samples three times daily for 3 days to assess concentrations of salivary alpha amylase (sAA) - a surrogate marker for autonomic nervous system (ANS) activity and, in particular, sympathetic activity - in sexually abused adolescent girls. Twenty-four girls (mean age: 15±1.4 years) who had experienced recent sexual abuse (i.e., sexual abuse occurred 1-6 months prior to study enrollment) and 12 healthy comparison subjects (mean age: 14.8±1.3 years) completed a structured interview and assessments to ascertain symptoms of posttraumatic stress, then collected saliva at home upon awakening, 30 minutes after waking, and at 5 p.m. on three consecutive school days. For sexually abused girls, total PTSD symptoms were associated with higher overall morning levels of sAA (r[20]=0.51, p=0.02), a finding driven by intrusive symptoms (r[20]=0.43, p<0.05) and hyperarousal symptoms (r[20]=0.58, p=0.01). There were no significant differences in diurnal sAA secretion between the sexually abused girls and healthy comparison adolescents. Overall morning concentrations of sAA in sexually abused girls are associated with overall PTSD severity as well as symptoms of hyperarousal and intrusive symptoms, possibly reflecting symptom-linked increases in ANS tone. These data raise the possibility that alterations in ANS activity are related to the pathophysiology of sexual abuse-related PTSD in adolescent girls, and may inform therapeutic interventions (e.g., antiadrenergic medications).
    Full-text · Article · Mar 2015 · Journal of child and adolescent psychopharmacology
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    • "Similarly, the Veterans Administration recommends the use of prazosin to improve sleep quality and reduce trauma nightmares (US Department of Veterans Affairs, 2010). Five randomized controlled trials examining the effect of prazosin on trauma-related nightmares that have been conducted to date (see Table 1 and Kung et al., 2012 for a full review of this literature). "
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    ABSTRACT: Interest in the treatment of nightmares has greatly increased over the last several years as research has demonstrated the clinical significance of nightmare disorder. This paper provides an overview of nightmare disorder, its clinical relevance, and the leading treatments that are available. In particular, the paper defines nightmare disorder and then summarize the recent literature examining the clinical relevance of nightmare disorder, including its relation to post-traumatic stress disorder and other psychiatric conditions. The relation between nightmares and suicidality is also discussed. Recent findings on the treatment of nightmare with imagery rehearsal therapy and prazosin are then summarized. Lastly, the paper comments on potential future uses of nightmare treatment including using imagery rehearsal therapy or prazosin as a first-line intervention for post-traumatic stress disorder and using these treatments as an adjunctive therapy to reduce suicide risk in those at risk of suicide with nightmares.
    Full-text · Article · Jun 2014 · International Review of Psychiatry
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    • "Hydrocortisone might also be a potential option in the treatment of PTSD due to its inhibiting effect on the intrusive rehearsal of traumatic memories.26 A methodologically well-designed crossover study in a very small sample of patients with chronic PTSD after a terroristic attack demonstrated confirming effects in accordance with the hypothesis.99 The α1 antagonist prazosin refers to an empirically well-established evidence of efficacy in improving PTSD-associated sleep disturbances and nightmares and additionally contributing to an overall reduction of PTSD core symptoms.100-102 "
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    ABSTRACT: Post-traumatic stress disorder (PTSD) may be associated with long-lasting psychological suffering, distressing psychosocial disability, markedly reduced health-related quality of life, and increased morbidity and mortality in a subgroup of individuals in the aftermath of serious traumatic events. Both etiopathogenesis and treatment modalities of PTSD are best conceptualized within a biopsychosotial model. Pharmacotherapy may lay claim to a major role in the multimodal treatment approaches. Here we outline two different pharmacotherapeutic trends that aim to modify the encoding, consolidation, and rehearsal of traumatic memory in order to reduce the risk of PTSD immediately after trauma exposure on the one hand, and that endeavor to treat the clinical state of PTSD on the other. The theoretical rationales of both pharmacological strategies are the complex neurobiological underpinnings that characterize traumatic memory organization and clinical PTSD. Meanwhile, promising data from randomized controlled trials have been obtained for both approaches. Empirical evidence may inform clinicians in their clinical efforts for this special group of patients. The efficacy of several classes of drugs that have been investigated within a context of research should be evaluated critically and still have to stand the test of effectiveness in daily clinical practice. From a patient perspective, empirical results may serve as a psychoeducative guideline to what pharmacotherapeutic approaches may realistically achieve, what their risks and benefits are, and what their limits are in contributing to reducing the often major chronic suffering caused by serious traumatic events. Ethical issues have to be considered, particularly in the context of pharmacological strategies projected to prevent PTSD in the aftermath of traumatic exposure.
    Full-text · Article · Jun 2014 · Dialogues in clinical neuroscience
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