Prazosin Treatment of an Adolescent with Posttraumatic Stress Disorder

Case Report

Ms. A is a 16-year-old female with acute PTSD, according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) criteria (American Psychiatric Association 2000), that occurred as a result of an armed robbery at an after-school job wherein a gunshot was fired above her and she was forced to remove money from the cash register. During the month since the robbery, she complained of initial insomnia, severe nightly nightmares associated with middle insomnia, intrusive symptoms, and hyperarousal symptoms. She was unable to return to work or to the neighborhood in which she had been working. At initial presentation Ms. A had a Clinician-Administered PTSD Scale (CAPS) score of 67 (re-experiencing, 20; avoidant, 18; hyperarousal, 29)

Prazosin was initiated at 1 mg every evening (QHS), and she reported less frequent but persistent nightly nightmares; she noted that she was able to return to sleep within 10 minutes of these nightmares. One week later, prazosin was increased to 2 mg QHS, at which time she began to report complete resolution of the nightmares. She reported no adverse events. Over the next month, she continued to report the absence of nightmares, normal sleep latency, and attenuation of hyperarousal symptoms, although there was little change in her avoidant symptoms, i.e., not returning to the neighborhood in which she had been working. Following 1 month of treatment, Ms. A's CAPS score decreased to 40 (re-experiencing, 6; avoidant, 20; hyperarousal, 14).

Discussion

This case is the first report of the use of prazosin monotherapy in an adolescent with PTSD and extends the findings of double-blind placebo controlled trials of this agent in adults and one prior report of adjunctive prazosin in an adolescent girl with PTSD (Brkanac et al. 2003). With regard to current available data to guide child and adolescent psychiatrists, two double-blind trials of selective serotonin reuptake inhibitors (SSRIs) do not support the efficacy of these agents in youths with PTSD (Cohen et al. 2007; Robb et al. 2008). Thus, our choice of prazosin as a first-line treatment was guided by the lack of efficacy data for SSRIs in children and adolescents with PTSD, the rapid symptomatic relief observed in double-blind, placebo-controlled trials of prazosin in adults with PTSD, and our patient's severe symptoms and functional impairment. Of note, the prazosin doses that have been used to treat adolescents with PTSD have generally been lower than those used in the treatment of adults with PTSD. It remains to be determined if this relates to physiological differences in the developing adrenergic system, pharmacodynamic or pharmacokinetic differences, or other factors. Moreover, as has been suggested in previous reports, prazosin appears to be selectively effective for the management of intrusive and hyperarousal symptoms. The onset of action was rapid with reduction of nightmare frequency and severity; onset of maximum efficacy occurred within 2 weeks, and the effect was sustained over the treatment period. However, despite the patient's improvement in intrusive and hyperarousal symptoms, minimal improvement was evident in avoidant symptoms. Indeed intrusive symptoms such as nightmares are thought to be related to noradrenergic hyperactivation observed in PTSD (Geracioti et al. 2001), and similar hyperadrenergic states have been also observed in traumatized pediatric patients De Bellis et al. 1994). Future studies examining the effects of prazosin in adolescents with PTSD are necessary.