PTSD Nightmares — MRCPsych Paper B MCQ

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HardAnxiety & Stress-Related DisordersPTSD NightmaresMRCPsych Paper B

A 27-year-old man with PTSD has completed an adequate course of trauma-focused CBT. Most daytime symptoms have improved, but he continues to experience frequent, distressing trauma-related nightmares. Which medication has the most direct placebo-controlled evidence for reducing this residual symptom, rather than merely causing nonspecific sedation?

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Correct answer: A — Prazosin

Prazosin is correct. This alpha-1 adrenoceptor antagonist has direct randomised and meta-analytic evidence for reducing PTSD-related nightmare severity, although its effect on global PTSD symptoms is less consistent. That symptom-specific evidence distinguishes it from medicines used principally for nonspecific insomnia. In UK practice, prescribing prazosin for PTSD nightmares is off-label; blood pressure, interacting medication and vulnerability to syncope should be assessed, with cautious titration because of first-dose and postural hypotension. Zopiclone is a nonspecific hypnotic without established efficacy for trauma-related nightmares and carries dependence risk. Trazodone is sometimes used for insomnia, but its nightmare-specific evidence is limited. Melatonin and promethazine likewise lack comparable direct evidence for PTSD-related nightmares. Trauma-focused psychological treatment remains the core intervention.

Reference: Mendes DD et al. Factors impacting prazosin efficacy for nightmares and insomnia in PTSD patients: a systematic review and meta-regression analysis. 2025. https://pubmed.ncbi.nlm.nih.gov/39828080/