Medications to Treat Trauma, Part 3: The Role of Adrenaline Blockers in Treating Trauma

As discussed in my previous posts on trauma treatment, medications are not a complete solution but serve as powerful tools to alleviate symptoms of developmental trauma and PTSD, enhancing the effectiveness of trauma-informed psychotherapy. (https://www.drjonslaughter.com/post/understanding-trauma-how-medications-help-with-ptsd-and-developmental-trauma)

This post builds on that series, focusing on the practical use of adrenaline blockers, specifically prazosin and beta-blockers like propranolol. For further context, refer to my earlier post on serotonergic medications, The Use of SSRIs and Other Serotonergic Medications in Treating Trauma. My clinical approach prioritizes using the lowest effective medication dose to minimize distress and improve functioning while reducing the risk of side effects. To illustrate, let’s revisit the clinical example of Anne, with a slight variation from the previous post: here, Anne’s depressive symptoms are less prominent, allowing us to focus on how adrenaline blockers can address her PTSD symptoms.

Prazosin acts "at the source" of the trauma response, significantly reducing PTSD symptoms.

Case Study: Anne’s Experience

Anne, a 42-year-old architect, presented at her first appointment reporting intense “anxiety,” difficulty falling asleep, and problems with concentration that were interfering with her work. She had previously been in therapy with limited benefit after an anxiety diagnosis and now is wondering if she might also have ADHD. This is a very common clinical picture. Since she has had trouble with attention and concentration she could easily be misdiagnosed with ADHD as the research shows that most mental health practitioners still do not practice trauma informed care..

After taking a full trauma history, it becomes clear that Anne has various symptoms of hyperarousal consistent with PTSD from childhood trauma. She experienced multiple traumatic experiences to include consistent verbal and emotional abuse escalating to being physically threatened and hit by her parent on a number of occasions, as well as being bullied throughout middle school. She describes persistent emotional distress with feelings of anxiety, powerlessness, and inadequacy when interacting with others, especially her supervisor at work and her partner when there is conflict between them. She reports having “impostor syndrome” at work.

In addition to emotional distress, her most prominent symptoms are intrusive thoughts of something bad happening, physical symptoms of racing heart and feeling a pit in her stomach, irritability, disrupted sleep, nightmares, and hypervigilance leading her to avoid others and situations that cause her distress. Her difficulty with concentration and attention started in childhood. These developed because of the impact her persistent state of fear and hyperarousal had on the formation of the frontal lobes of her brain, as these are the parts of the brain responsible for attention and impulse control. In regards to the latter she does report some challenges with this, drinking more than intended at times, with a brief period of daily drinking in the past, and engaging in some risky sexual behaviors when she was younger. Since she had these symptoms of poor attention and impulse control she could easily have been misdiagnosed with ADHD when in fact it was her trauma that caused these challenges.

As you can see from the above Anne is not just suffering with “anxiety.” Her symptoms are more complex than generalized anxiety. Anne also reports feeling sad and down some days. She has had one prior period of more prominent depressed mood in the past. During this episode her down mood impacted her energy and interest levels. This is sadly a common pattern in those who have lived through developmental or discreet traumas (such as an assault). When one remains in a persistent state of hyperarousal it can eventually begin to pull one’s mood down leading to the onset of other depressive symptoms.

Two primary medication classes are effective as the backbone of a regimen for PTSD: serotonergic medications and adrenaline blockers. These are typically taken daily, either alone or in combination. The decision to use medication involves weighing potential benefits against risks, including side effects and interactions with other medications. This post focuses on adrenaline blockers. I wrote about serotonergic medication in my last post. (https://www.drjonslaughter.com/post/the-use-of-ssris-and-other-serotonergic-medications-in-treating-trauma) 

Sustainable healing from trauma combines medications like prazosin with trauma-informed psychotherapy and mindfulness.

Adrenaline Blockers: Mechanism and Use

Adrenaline blockers, including prazosin (an alpha-blocker) and propranolol (a beta-blocker), target the body’s adrenaline receptors to mitigate the fight-flight-freeze response central to PTSD.

Prazosin

Prazosin blocks alpha adrenergic receptors in the brain’s threat detection networks. When a threat is perceived, excitatory signaling triggers the hypothalamus to release hormones, prompting the adrenal glands to secrete adrenaline and cortisol. Adrenaline then binds to alpha receptors, amplifying the fight-flight-freeze response. By occupying these receptors, prazosin “hits the brakes,” reducing the intensity of trauma responses or preventing them entirely when triggered. This can interrupt the physiological cascade that leads to overwhelming symptoms.

Initially recognized for reducing nighttime hyperarousal symptoms like disrupted sleep and nightmares, prazosin has also proven effective for daytime symptoms, including emotional distress, physical reactivity, intrusive thoughts, irritability, and hypervigilance. Over time, consistent reduction of hyperarousal can improve cognitive and depressive symptoms, providing comprehensive relief for PTSD.

Evidence Supporting Prazosin for PTSD

Two key studies provide evidence for prazosin’s effectiveness in managing PTSD symptoms:

1. Raskind et al. (2003) demonstrated that veterans with PTSD treated with prazosin experienced significant reductions in trauma-related nightmares and improved sleep quality compared to a placebo group, highlighting its efficacy in addressing hyperarousal.

2. Taylor et al. (2008) found that prazosin reduced nightmare frequency and overall PTSD symptom severity in civilians, supporting its broader applicability.

Propranolol

Propranolol, a beta-blocker, targets beta receptors primarily in end-organ tissues like the heart, lungs, and muscles, which are activated during the fight-flight-freeze response. This causes physical symptoms such as racing heart, shortness of breath, muscle tension, sweating, and gastrointestinal discomfort—often referred to as a “panic attack” though in trauma survivors this is not due to simple anxiety. Unlike prazosin, propranolol is typically used as needed rather than daily and cannot be combined with prazosin due to the risk of synergistic effects causing dangerously low blood pressure. A future post will explore propranolol and other as-needed medications for trauma.

What to Expect with Prazosin

Unlike SSRIs, which mute trauma symptoms, prazosin targets the source of the trauma response by blocking adrenaline’s effects in the brain and body. It is started at a low dose (e.g., 1 mg) before bed to minimize the risk of low blood pressure, with gradual increases at bedtime with daytime doses eventually being introduced. Some fortunate individuals start to experience improved sleep quality and less nightmares immediately with the first dose. For most people these improvements come after one reaches a higher dose. For many, a target dose to experience improvement is 5mg twice per day though some will need to go higher than this. It takes 3-4 weeks to reach this dose for most. When effective, prazosin reduces daytime hyperarousal symptoms, as seen in Anne’s case below. Sustainable healing comes from engagement with non-medication interventions, such as trauma-informed psychotherapy and regular compassion-focused mindfulness practices, once symptoms are manageable.

Anne’s Experience with Prazosin

After discussing treatment options, Anne started prazosin at 1 mg before bed, increasing to 3 mg after a week. She reported significantly less disrupted sleep and fewer, less intense nightmares, which helped her feel calmer upon waking. After incremental increases to 4 mg in the morning and 6 mg at bedtime, Anne experienced reduced daytime hyperarousal, including less emotional distress, fewer physical symptoms, and lower hypervigilance. This allowed her to engage more comfortably with her partner and supervisor. After two months at her optimal dose, her mild depressive symptoms resolved, and within another month, her attention and concentration improved, restoring her previous level of functioning.

Potential Side Effects of Prazosin

The primary concern with prazosin is low blood pressure, as alpha receptors are also present in blood vessels. Originally developed for hypertension, prazosin is less effective for this purpose but can cause significant blood pressure drops in some individuals, potentially leading to dizziness or fainting. To mitigate this, prazosin is started at bedtime when patients are already lying down, as lying down or elevating the feet counteracts low blood pressure. Patients are advised to sit on the bed for 1–2 minutes upon waking to check for lightheadedness, which can also serve as a moment for self-compassion mindfulness practice. Staying hydrated and, if desired, monitoring blood pressure with a cuff can further ensure safety.

Other potential side effects include:

• Headache: Common with medications affecting the brain, usually mild and resolving within weeks.

• Somnolence: A small percentage of patients experience persistent morning sleepiness, typically evident after the first dose, indicating potential intolerance.

• Palpitations: Reported in up to 5% of users, requiring monitoring and possible discontinuation if persistent.

Deprescribing

Once an effective regimen is established, I recommend continuing prazosin for at least six months to allow recovery from prolonged distress. Sustained symptom reduction can decrease excitatory brain signaling, reducing the fight-flight-freeze response over time. Deprescribing should be gradual to prevent symptom recurrence and depends on engagement in non-medication strategies like trauma-informed psychotherapy, self-compassion practices, and mindfulness or distress tolerance skills from Dialectical Behavioral Therapy (DBT). My YouTube channel offers mindfulness and compassion-focused meditations to support healing [Insert YouTube Link]. If symptoms return after deprescribing, non-medication strategies may suffice, though restarting prazosin may be necessary.

Conclusion

I empathize with those struggling with trauma and hope this post, part of my series on trauma treatment, provides valuable insights. Explore my posts on non-medication tools and my series Let Thy Food Be Thy Medicine [https://www.drjonslaughter.com/post/omega-3-benefits-for-brain-health-salmon-recipe] for additional resources to support your healing journey.

References

• Raskind, M. A., Peskind, E. R., Kanter, E. D., et al. (2003). Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: A placebo-controlled study. American Journal of Psychiatry, 160(2), 371–373.

• Taylor, F. B., Martin, P., Thompson, C., et al. (2008). Prazosin effects on objective sleep measures and clinical symptoms in civilian trauma PTSD: A placebo-controlled study. Biological Psychiatry, 63(6), 629–632.

Disclaimer

This blog is for informational and educational purposes only and is not medical advice, diagnosis, or treatment. Information about psychiatric medications, their uses, or side effects is general and not a substitute for professional medical advice from a licensed psychiatrist or healthcare provider. Always consult a qualified healthcare professional before starting, stopping, or modifying any medication or treatment plan. Individual responses to medications vary, and only a licensed professional can assess your specific needs. The author is not responsible for any adverse effects or consequences from using this information. By reading, you acknowledge that this content is not a replacement for professional medical care and assume all risks of applying or misinterpreting it.