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56-year-old patient with history of PTSD

A fifty-six-year-old male presents with history of post-traumatic stress disorder due to childhood physical abuse. He has trouble sleeping due to flashbacks, which he has had since his teenage years. He has tried therapy and EMDR, but continues to face insomnia. The patient reports falling asleep during the day, and having no trouble falling asleep at night. He reports that he struggles to stay asleep for more than forty-five minutes at one time. He does not note having any dreams. He denies any illicit drug, alcohol, or tobacco use. He lives by himself and is employed at a local marketing agency, where he manages technical infrastructure.

1. What treatment options would you offer this patient?

2. How would you recommend approaching testing this patient for any comorbidities?

  • from Doctor Unite 4 weeks
    You could use a sleep aid such as gaba or trazodone as well
  • from Doctor Unite 4 weeks
    I am a big advocate for therapy for this patient given his problems from his past.
  • 4 weeks 1 day
    then will try xywav for norcolepsy if medically confirmed
  • 4 weeks 1 day
    also first line medication always remained SSRI for PTSD if diagnosis confirmed and therapy not working , any kind of antiadrenergic medications like prazosin , clonidine or inderal will be added in addition to SSRI to help for anxiety .
  • 4 weeks 1 day
    would ask some more history related about sleep ,mood and substance use issue , getting collaterals from patients family and previous records reviewed will be first priority , then think about ruling out medical causes of insomnia ..
  • 1 month
    may consider prazosin BID to help with daytime flashbacks and night time sleep, nightmare and sleep quality. may consider clondine patch as well for similar reasons. may consider doxepin or mirtazapine for improving sleep duration.
  • from Doctor Unite 1 month
    I would explore more history of his insomnia, his Sleep diary. And sleep questionnaire for insomnia screening. Prazosin will help for nightmares and will add doxepin /Orexin antagonist to maintain sleep.Trazadone may cause unwanted drowsiness and other side effects ,also can potentiate prazosins side effects.His day time sleepiness could be due to night time insomnia.i doubt he has Sleepapnea or Narcolepsy. Ofcourse he need to maintain sleep hygiene .Rao Gudapati
  • from Doctor Unite 1 month
    Has he tried Doxepin (25-50mg @HS) or trazodone (50-150@HS)???
  • from Doctor Unite 1 month
    Rather than jump to pharmacological therapies I would start with a sleep study and endocrine and metabolic work up (ie tsh, glucose). Counseling for his PTSD may also be helpful. Central sleep apnea is also a concern as well as knowing his BMI. If pharmacological therapy is to be initiated, an SSRI or Melatonin can help his impaired circadian sleep cycle.
  • 1 month
    I would start with a sleep study as he reports no difficulty with falling asleep but more maintaing sleep. BMI of corse is important as well as any metabolic factors.
    An SSRI could be considered as well as Melatonin as his circadian sleep cycle is probably impaired.
    Prazosin could be beneficial depending on response.
    I would NOT prescribe hypnotics for sleep as short term indication and this seems to be more chronic from previous trauma.
  • 1 month
    se non phar,macological approach to help with sleep
  • from Doctor Unite 1 month
    I would recommend looking at his BMI and try trazodone. A sleep study may be informative
  • from Doctor Unite 1 month
    SNRI and Orexin inhibitors ie. Effexor or Duloxetine combination with Belsomra or Dayvigo. The former have worked well with my PTSD patients and the latter maintain sleep.
  • from Doctor Unite 1 month
    after a sleep study I would first try non-Rx interventions (melatonin and/or magnesium) followed by tiered approach first with prazosin followed by belsomra if unsuccessful
  • 1 month
    Right off the bat I would work up this patient for Sleep apnoea as he surely has excessise daytime sleepiness plus difficulty maintaining sleep.Once that is ruled out certainlly consider agents helpful with maintaining sleep.Also option of Prazosin is valid one if not already tried.
  • from Doctor Unite 1 month
    Xywav could be beneficial.
  • from Doctor Unite 1 month
    I would do a complete history and physical exam. What is his BMI? family history? Get some labs such as CBC, CMP, tsh, a1c, lipids, vitamin levels. Getting a sleep study would be useful. Also referring patient to psych and therapy as an approach to treat his PTSD. I would also recommend a sleep diary for this patient. I would like to wait for the results before initiating any treatment.
  • from Doctor Unite 1 month
    Try Belsomra or Davigo
  • from Doctor Unite 1 month
    I would try a tiered approach to treatment starting with therapy, then trialing prazosin, and if that was ineffective I would try trazodone. I would also work up the patient for OSA with a sleep study.