How can I stop having dreams, specifically using Prazosin (an alpha-1 adrenergic receptor blocker)?

Treatment Options for Stopping Dreams: Focus on Prazosin

For stopping dreams, particularly nightmares, Image Rehearsal Therapy (IRT) is the most strongly recommended first-line treatment, while prazosin may be used as a pharmacological option for nightmare disorder and is particularly effective for PTSD-associated nightmares. 1

Non-Pharmacological Approaches (First-Line)

Image Rehearsal Therapy (IRT)

• Strongest recommendation with Level A evidence for both PTSD-associated nightmares and nightmare disorder 1
• Technique:
  • Recall the nightmare and write it down
  • Change the theme, storyline, ending, or any part to a more positive scenario
  • Rehearse the rewritten dream for 10-20 minutes daily while awake
  • This helps inhibit the original nightmare through cognitive shifting 1
• Effectiveness:
  • Reduces nightmare frequency by 60-72% 1
  • Effects maintained at 3,6, and even 30-month follow-ups 1
  • Also improves sleep quality and reduces distress 1

Other Non-Pharmacological Options

• Cognitive Behavioral Therapy (CBT)
• Exposure, Relaxation, and Rescripting Therapy
• Lucid Dreaming Therapy
• Progressive Deep Muscle Relaxation
• Systematic Desensitization

Pharmacological Approach: Prazosin

Mechanism and Efficacy

• Prazosin is an alpha-1 adrenergic receptor blocker that reduces elevated CNS noradrenergic activity associated with nightmares 2
• Particularly effective for PTSD-associated nightmares but also listed as an option for general nightmare disorder 1, 2
• Significantly increases total sleep time (by 94 minutes in one study) and REM sleep time 3
• Reduces trauma-related nightmares and distressed awakenings 3, 4

Dosing Protocol

1. Starting dose: 1 mg at bedtime with monitoring for hypotension after first dose 2, 5
2. Titration: Increase by 1-2 mg every 3-7 days until effective 2
3. Typical maintenance doses:
   • General population: 3-15 mg daily 2, 5
   • Women: Average 7.0 mg 2
   • Men: Average 15.6 mg 2
   • Military veterans: Higher doses (10-16 mg) 2, 5
   • Some refractory cases: Up to 30-45 mg (in case reports) 6

Monitoring and Side Effects

• Blood pressure monitoring is essential, especially after first dose and during titration 2, 7
• Common side effects:
  • Orthostatic hypotension (first-dose phenomenon)
  • Dizziness
  • Drowsiness
  • Headache 2, 7
• Response typically occurs within weeks 5

Treatment Algorithm for Stopping Dreams

1. First-line: Image Rehearsal Therapy (IRT) - most strongly recommended by guidelines 1

2. For those who need medication or have PTSD-associated nightmares:

   • Start prazosin at 1 mg at bedtime
   • Monitor blood pressure after first dose
   • Gradually increase by 1-2 mg every 3-7 days
   • Target dose based on patient population (typically 3-15 mg)
   • Assess response after 4-6 weeks at maximum tolerated dose

3. If inadequate response to prazosin:

   • Consider alternative medications: clonidine, atypical antipsychotics (olanzapine, risperidone), or topiramate 1, 2
   • Consider switching to doxazosin if prazosin is not tolerated 2

4. Combination approach:

   • For partial response, combine IRT with medication therapy 2

Common Pitfalls to Avoid

• Underdosing prazosin, particularly in male veterans who typically require higher doses 2
• Failing to monitor blood pressure when initiating prazosin therapy 2
• Discontinuing treatment prematurely before adequate dose titration 2
• Not considering non-pharmacological treatments like IRT, which has the strongest evidence base 1, 2
• Using medications not recommended for nightmare disorder such as clonazepam and venlafaxine 1

Remember that the ultimate treatment decision should be based on the specific type of dreams (nightmares vs. normal dreams), their frequency, associated conditions (like PTSD), and the impact on quality of life and daily functioning.