Clinical Case Series: The Use of Prazosin for Combat-Related Recurrent Nightmares among Operation Iraqi Freedom Combat Veterans

Military Medicine, Jun 2005 by Daly, Christine Maura, Doyle, Michael E, Radkind, Murray, Raskind, Elaine, Daniels, Colin

Conclusions from these anecdotal observations must be considered preliminary, for a number of reasons. It is always possible in an open-label trial that nightmare reduction, even of the observed magnitude, was attributable to a placebo effect or the psychotherapeutic effects of being treated in a mental health setting. Also, some of the psychotropic medications being taken by more than one-half of these soldiers could have contributed to the symptomatic improvement observed during Prazosin treatment. Conversely, selective serotonin reuptake inhibitors could have intensified nightmares and sleep disturbances.3 Because combat-related nightmares were not reported to have been influenced for better or worse by these medications, it is more likely that the observed nightmare reductions were attributable to Prazosin. Temporally, combat-related nightmares almost always were reduced or completely eliminated after the initiation or increase in Prazosin therapy, while the other medications remained unchanged.

It would have been more informative to have used multiple valid, reliable, rating scales to quantify nightmare frequency and intensity, sleep disturbances, other PTSD symptoms, mood symptoms, and quality of life. Unfortunately, these intensive assessments were not feasible in our busy clinic. More objective symptom ratings will be included in future, placebo-controlled, Prazosin trials. Limiting assessments to global change evaluations with the Clinical Global Impression of Change likely caused useful information to have been missed but did provide standardization of treatment response assessments. Furthermore, this patient group was not a random sample of OIF veterans with combat-related nightmares but was a self-referred, "help-seeking" group willing to admit on a postdeployment questionnaire that combat-related nightmares were a serious problem. The fact that none of the patients were abusing alcohol or other drugs as "self-medication" for nightmares and sleep disturbances (at least by self-report) might also have been atypical.

Combat-related nightmares that occur soon after evacuation from theater may represent a normal psychologic response to stress that potentially could resolve over days or weeks. However, for the patients included in this analysis and represented in the case presentations, the nightmare symptoms had persisted for months and continued to be distressing enough at the time of presentation to prompt immediate treatment. In addition, these soldiers' traumatic combat events had occurred >4 weeks before their return to their home base and thus had persisted beyond the time period acceptable for a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of acute stress disorder. The persistence and intensity of the nightmares and the lack of clinical improvement over time again are consistent with trauma nightmares in the context of PTSD.1

Previous Prazosin studies focused on the amelioration of nightmares among Vietnam era veterans with PTSD. Prazosin dosages that appeared effective in our study population were low (typical doses of 1 or 2 mg at night), compared with typical doses used in treating Vietnam era veterans (5-10 mg at night). Several differences in the populations emerge as possible factors for the discrepancy in required dosages, i.e., (1) our sample was young and, in general, free of medical and comorbid psychiatric disorders; (2) the exposure to combat stress in our population was recent, rather than decades in the past; and (3) the Vietnam veterans had been maintained on a larger number and wider variety of concurrent psycho tropic medications, and many had histories of alcohol abuse.14,15 However, the similarly robust reductions of combat-related nightmares during Prazosin treatment among recently combat-exposed OIF veterans and remotely combat-exposed Vietnam veterans suggest a common pathophysiologic process, involving enhanced CNS α^sub 1^-adrenergic receptor responsiveness, in both groups.