Question
30-year-old man comes to the Veterans Affairs hospital because of difficulty sleeping for the past 9 weeks. He is a soldier who returned from a deployment in Afghanistan 12 weeks ago. Fifteen weeks ago, his unit was ambushed in a deserted street, and a fellow soldier was killed. He wakes up frequently during the night from vivid dreams of this incident. He blames himself for being unable to save his friend. He also has trouble falling asleep and gets up earlier than desired. During this period, he has started to avoid walking in deserted streets. Vital signs are within normal limits. Physical examination shows no abnormalities. He refuses cognitive behavioral therapy and is started on sertraline. Five weeks later, he returns to the physician and complains about persistent nightmares and difficulty sleeping. Which of the following is the most appropriate next step in management?
| A. |
Phenelzine therapy
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| B. |
Prazosin therapy
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| C. |
Supportive psychotherapy
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| D. |
Interpersonal therapy
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Show Answer
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Correct Answer � B
Explanation
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Prazosin therapy
Phenelzine therapy
Phenelzine is a nonselective monoamine oxidase inhibitor (MAOI) that may be used to treat insomnia in patients with PTSD who do not respond to other treatment. MAOIs are not preferred as first-line pharmacotherapy in PTSD due to their potentially harmful side effects (hypertensive crisis if co-ingested with tyramine-containing foods, serotonin syndrome, and risk of fatal overdose).
Prazosin therapy
Prazosin therapy decreases the frequency of nightmares and improves sleep quality in patients with PTSD. Since this patient has vivid dreams of the traumatic incident on a regular basis, difficulty falling asleep, and poor sleep quality despite using SSRIs (sertraline), a trial of prazosin would be indicated. Ideally, PTSD is treated with a combination of cognitive behavioral therapy and pharmacotherapy. The first-line pharmacotherapy in patients with PTSD is an SSRI (e.g., paroxetine, fluoxetine).
Supportive psychotherapy
Supportive psychotherapy focuses on guidance, reinforcement, and encouragement to build self-esteem and improve functioning in social environments for patients suffering from anxiety disorders. However, exposure-based or trauma-focused cognitive behavioral therapy (which involves having the patient repeatedly re-experience the traumatic event) is the psychotherapy of choice in patients with PTSD.
Interpersonal therapy
Interpersonal therapy is mainly used in the management of patients with depression, since these patients often have difficulties interacting with others. Trauma-focused or exposure-related cognitive behavioral therapy (which involves having the patient repeatedly re-experience the traumatic event) is the psychotherapy of choice in patients with PTSD, however; it aims to alter the distorted and irrational beliefs/attitudes (guilt and blaming oneself, in this case) from which these patients suffer
