A 28-year-old woman comes to the office for follow-up of an 8-month history of anxiety, nightmares, and flashbacks after returning from a military deployment. She has been taking sertraline for the past 6 months and completed a course of cognitive-behavioral therapy recently. The patient reports her symptoms have mostly improved, and she no longer has intrusive thoughts or flashbacks related to her time in a combat zone. She says, "My mood feels lighter, and I've started spending more time with friends and family. I can't seem to sleep through the night though. I'm still having scary dreams about my time in the army." She drinks a glass of wine twice a week and does not use tobacco or illicit drugs. Medical history is noncontributory. Vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the best next step in management of this patient?

Question

A 28-year-old woman comes to the office for follow-up of an 8-month history of anxiety, nightmares, and flashbacks after returning from a military deployment.  She has been taking sertraline for the past 6 months and completed a course of cognitive-behavioral therapy recently.  The patient reports her symptoms have mostly improved, and she no longer has intrusive thoughts or flashbacks related to her time in a combat zone.  She says, "My mood feels lighter, and I've started spending more time with friends and family.  I can't seem to sleep through the night though.  I'm still having scary dreams about my time in the army."  She drinks a glass of wine twice a week and does not use tobacco or illicit drugs.  Medical history is noncontributory.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d7ee_c8fd_bc81_2b70c762331c_MD0003_00 First-line treatment for posttraumatic stress disorder (PTSD) includes trauma-focused cognitive behavioral psychotherapy and pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI). This patient's symptoms of PTSD have improved with psychotherapy and sertraline, but she continues to experience distressing nightmares. Meta-analyses have shown that prazosin, an alpha-1 adrenergic receptor antagonist, is effective for treatment of PTSD-related nightmares and is particularly helpful as an adjunct to SSRI or SNRI treatment. Prazosin is thought to reduce nightmare frequency by decreasing the adrenergic hyperactivity found in many patients with PTSD. Prazosin is administered at bedtime and requires titration to reduce the risk of effects on blood pressure (eg, orthostasis). (Choice A) Benzodiazepines (eg, clonazepam) are not effective in the treatment of PTSD-related nightmares and carry risks of addiction and dependence. They should particularly be avoided in patients with an active substance use disorder. (Choice B) There is no evidence that psychodynamic psychotherapy can effectively target PTSD-related nightmares. Exposure-based cognitive-behavioral therapy (CBT) is the therapy of choice for PTSD; CBT techniques to target nightmares specifically include image rehearsal therapy, in which nightmares are rewritten with a positive outcome. (Choice D) This patient's PTSD symptoms have improved significantly on sertraline. There is no evidence that paroxetine is more effective in treating nightmares than other SSRIs, and switching antidepressants could risk worsening other PTSD symptoms. (Choice E) This patient is benefiting from sertraline, and tapering risks relapse. Educational objective: Prazosin, an alpha-1 adrenergic receptor antagonist, is effective for the treatment of posttraumatic stress disorder-related nightmares. It is particularly helpful as an adjunct to selective serotonin reuptake inhibitor or serotonin norepinephrine reuptake inhibitor treatment. References: Comparative efficacy of imagery rehearsal therapy and prazosin in the treatment of trauma-related nightmares in adults: A meta-analysis of randomized controlled trials (http://www.ncbi.nlm.nih.gov/pubmed/31855732)

A 28-Year-Old Woman Comes to the Office for Follow-Up of an 8-Month