been reported to increase after its administration, as stress-related nightmares decrease. In addition, using it has led to a decrease in difficulties falling asleep and staying asleep. A decrease in PTSD symptoms other than those associated with sleep and decreased ratings of depression have also been reported. One study reported that prazosin was associated with increased total sleep as well as more REM sleep (consistent with return of normal dreaming) as well as an increase in the number of eye movements during a period of REM sleep and less time between falling asleep and the first period of REM sleep. Patients who had failed to respond to other treatments (e.g., SSRIs tricyclic antidepressants (TCAs)) have responded to this drug, which may indicate the superiority of prazosin to these other treatments. On the other" "hand, since in many trials patients continued on previous medications, these results may indicate prazosin's use as an additional medication to SSRIs, tricyclic antidepressants, and others.

While many of the trials have been open trials, a number of them have been placebo-controlled and crossover, providing compelling evidence for the effectiveness of prazosin. While protocols using up to 20 mg have been described, most studies have shown good results with 2 to 6 mg. Higher doses are divided, but doses of 2 to 6 mg are given at bedtime. A test dose of one mg is given, with the dosage increased every 3-7 days as needed until effective or until side effects decrease. While some patients experienced a drop in blood pressure when standing, many of these were also on anti-hypertensives or other cardiac medications. Prazosin's peak effect occurs 1 to 3 hours after being taken by mouth, its half-life is 2 to 3 hours, and its effect lasts 4 to 6 hours. The most common side

effect is nasal congestion, with hypotension and sedation being rare. Dosage increases may occasionally be required. A return of sleep problems occurs when a person stops using prazosin, consistent with prazosin suppressing nightmares rather than helping in the processing of

the underlying traumatic memories.

Thus, prazosin has demonstrated effectiveness in treating sleep disturbances and nightmares and has had a favorable effect on other symptoms of PTSD. Whether or not the decrease in symptoms, other than sleep symptoms, is secondary to improved sleep or pri

mary, prazosin should be considered a first-line medication for sleep disturbance. It avoids the potential disadvantages of other agents such as tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and benzodiazepines (used especially as tranquilizers), which include suicide risk, medical adverse effects, and in the case of benzodiazepines, substance abuse, and only has variable effectiveness.

"Medications may improve sleep and decrease nightmares while psychotherapy may help with the reprocessing of traumatic thoughts. Since at least some good-quality sleep is required for optimal reprocessing, the two techniques are likely complementary."

THOUGHTS IN THE FIELD

Despite the attention paid to sleep disturbances as symptoms that occur with PTSD, certain investigators think the importance of sleep disturbances may have been downplayed and that certain types have been neglected. They contend that insomnia and nightmares should be considered core symptoms of PTSD, which may actually cause and perpetuate the disorder. Furthermore, they suggest that sleep-disordered breathing (SDB) (abnormal breathing patterns that interfere with sleep) and periodic arm and leg movements in sleep (PLMS) are important contributors to PTSD sleep disturbances and have been largely ignored.

In support of the idea that sleep disturbances may cause PTSD, they cite studies reporting that sleep disturbances occurring during the period of the stress reaction right after the stressful event are strong predictors of the development of PTSD. There is even a report that sleep disturbances occurring before the stressor may predict the later occurrence of PTSD. The plausibility of these reports is supported by observations that sleep deprivation is well known to interfere with a person's ability to cope in general and to impair mood. Furthermore, as discussed, normal sleep, including REM, is thought to play a role in processing memories of trauma, which are central to PTSD. All of these may increase a person's vulnerability to PTSD. Consistent with this possibility, there are reports that early treatment of sleep disturbances during periods of acute stress may prevent the development of PTSD, and a number of studies have shown that treatments directed at sleep disturbances and nightmares may decrease other symptoms of PTSD. While treatments that focus on traumatic memories may decrease symptoms of PTSD, unless attention is