PTSD nightmares: practical outpatient options
Start with education and sleep basics. Add meds if needed.
First‑line medicine is prazosin. Titrate slow, watch BP.
Teach Imagery Rehearsal Therapy (IRT). It works and is brief.
Quick start
Explain nightmares in PTSD. Normalize and set a simple plan.
Sleep basics: fixed wake time, no alcohol near bed, limit late caffeine, wind‑down routine, dark/cool room.
Med options (adult outpatient)
Prazosin at bedtime. Start 1 mg qHS. Increase by 1 mg every few nights as tolerated (often 2–6 mg total; sometimes higher). Watch dizziness/orthostasis, check BP.
If prazosin not tolerated/ineffective, consider:
Clonidine or guanfacine for hyperarousal/sleep onset
Low‑dose trazodone or doxepin for insomnia features
Mirtazapine when depression/anxiety + poor appetite/weight loss
Check for OSA, pain, substance use, or meds that worsen sleep.
IRT in 5 minutes
Pick one frequent nightmare. Rewrite it with a safe/neutral ending.
Rehearse the new version while awake 5–10 minutes daily.
Practice for 2–4 weeks. Track frequency and distress.
Follow‑up plan
Recheck weekly during titration. Ask: time to fall asleep, awakenings, nightmare count, daytime function.
If better: hold dose and extend visit interval. If not: adjust dose or switch plan.
When to escalate
Syncope or severe orthostasis
High suicide risk or severe depression
Suspected OSA (snoring, pauses, daytime sleepiness) → sleep study referral
Want an IRT handout + prazosin titration card? I can add printable PDFs and smart phrases.