A 35-year-old woman with PTSD on sertraline 100 mg/day for 6 months has partial response. She continues to have hyperarousal and nightmares. Which second-line agent is specifically approved/recommended for PTSD nightmares?

• A Quetiapine 25 mg at bedtime
• B Propranolol (beta-blocker)
• C Clonazepam long-term
• D Prazosin (alpha-1 blocker) ✓

Explanation

Prazosin, an alpha-1 adrenergic antagonist, has the best evidence for reducing trauma-related nightmares in PTSD by blocking norepinephrine's action in the prefrontal cortex and amygdala during sleep. Multiple RCTs and VA/DoD guidelines support its use. Propranolol has shown some benefit for acute trauma memory consolidation but not chronic PTSD nightmares. Quetiapine is used for sleep but not specifically for PTSD nightmares as a guideline-recommended agent. Benzodiazepines are NOT recommended in PTSD guidelines due to lack of efficacy for PTSD core symptoms and risk of dependence.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.