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Somatic symptom disorder — USMLE Step 3 MCQ

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HardPsychiatry (Outpatient Management)Somatic symptom disorderUSMLE Step 3

A veteran with PTSD has substantial improvement in daytime intrusion, avoidance, and hyperarousal after trauma-focused psychotherapy and sertraline. Recurrent trauma-related nightmares remain disabling. Blood pressure is 132/78 mm Hg, and there is no orthostasis. Which targeted adjunct is reasonable?

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Correct answer: D — Offer cautiously titrated prazosin specifically for the persistent nightmares

The best answer is “Offer cautiously titrated prazosin specifically for the persistent nightmares”. The 2023 VA/DoD guideline suggests prazosin for PTSD-associated nightmares, with slow titration and monitoring for dizziness or orthostatic hypotension. That targeted recommendation should not be generalized to global PTSD symptoms, for which prazosin is not suggested. Benzodiazepines and routine antipsychotic augmentation have unfavorable evidence and risk profiles, and a hypnotic does not replace disorder-focused treatment.

Reference: VA National Center for PTSD: Clinician’s Guide to Medications for PTSD (2023 VA/DoD CPG): https://www.ptsd.va.gov/professional/treat/txessentials/clinician_guide_meds.asp