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Prazosin: The Best Medication for Comorbid PTSD? 

Why does prazosin appear to be the safest and most effective medication for select patients with comorbid PTSD? 

 and the Columbia University Breakthrough Session, hosts Angela Coombs, MD, and Jennifer Sotsky, MD, discuss the possibilities and promise of psilocybin to treat psychiatric disorders and in enhancing everyday experiences with 

. Landmark studies and new research about the use of hallucinogens includes potential to treat:

Posttraumatic stress disorder
Substance use disorders


Psilocybin (mushrooms) and other hallucinogens from plants and some animal life generate perceptual changes and hallucinations, altered physical sensations, strong emotional reactions, and even dissolution of self.

The question is whether these are 

 or trips and whether they can result in lasting changes in the patient. Over time, some of the brain connections may become disrupted and new circuits may become activated.

Dr Hellerstein is a professor of clinical psychiatry at Columbia University and is conducting clinical trials of psilocybin. His books include 

Heal Your Brain: How the New Neuropsychiatry Can Help You Go from Better to Well

is a board-certified psychiatrist and assistant professor in Clinical Psychiatry at Columbia University Medical Center and the New York State Psychiatric Institute. She serves as the medical director and team psychiatrist at ONTrackNY Washington Heights Community Service clinic. She completed her public psychiatry fellowship and adult psychiatry residency at Columbia University where she was a chief resident and co-organized the curriculum on racial/ethnic mental health disparities. In addition to her clinical work in the public sector, she also works in Columbia's psychiatric emergency room and has a private practice in Upper Manhattan.



is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part time private practice. She was formerly a chief resident at Columbia’s psychiatry residency program. Before medical training, she received an MS in Narrative Medicine, an interdisciplinary field that studies illness through a humanities lens. She is co-author of 

Conquering Lyme Disease: Science Bridges the Great Divide

 and has interests in medical education, psychotherapy, and medical humanities.



Columbia University Department of Psychiatry

 for allowing us to present the Breakthrough Session podcast with experts in the field of psychiatry.


Research on psilocybin, LSD, and other hallucinogens as psychiatric treatments are in their renaissance, transitioning from banned and illegal to potentially useful in changing life for the better in some patients. More in this podcast.

David Hellerstein, MD: Psychedelic Treatments for Psychiatric Disorders



In this installment of PsychPearls and the Columbia University Breakthrough Session, hosts Angela Coombs, MD, and Jennifer Sotsky, MD, discuss anxiety with 

Anxiety as cultural phenomenon vs individual illness

Help-seeking as a sign of strength and self-knowledge


Dr Albano is professor of medical psychology (in Psychiatry) at Columbia University and director of the 

Columbia University Clinic for Anxiety and Related Disorders

 (CUCARD). She is a clinical psychologist and board-certified in clinical child and adolescent psychology. In addition to serving as director of CUCARD, she also conducts research and trains residents, fellows, and psychology postdoctoral fellows and interns. Her research is focused on the development and testing of psychosocial treatments for anxiety and mood disorders, and in understanding the impact of these disorders on the developing youth. Dr Albano devotes her career to the study and treatment of anxiety and mood disorders in children, adolescents, and young adults. She is an expert diagnostician and cognitive-behavioral therapist. Dr. Albano co-developed a cognitive behavioral treatment program for adolescents with social phobia. She has published more than 90 articles and chapters and is the coauthor of several cognitive behavioral treatment manuals, including 

Anxiety Disorders Interview Schedule (ADIS-IV) Child and Parent Interview Schedules.

is a board-certified psychiatrist and assistant professor in Clinical Psychiatry at Columbia University Medical Center and the New York State Psychiatric Institute. She serves as the medical director and team psychiatrist at ONTrackNY Washington Heights Community Service clinic. She completed her public psychiatry fellowship and adult psychiatry residency at Columbia University where she was a chief resident and co-organized the curriculum on racial/ethnic mental health disparities. In addition to her clinical work in the public sector, she also works in Columbia's psychiatric emergency room and has a private practice in Upper Manhattan. 

 is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part time private practice. She was formerly a chief resident at Columbia’s psychiatry residency program. Before medical training, she received an MS in Narrative Medicine, an interdisciplinary field that studies illness through a humanities lens. She is co-author of 

Thanks to Columbia University Department of Psychiatry for allowing us to present the Breakthrough Session podcast with experts in the field of psychiatry.



A discussion with professor of medical psychology and director of the Columbia University Clinic for Anxiety and Related Disorders.

Anne Marie Albano, PhD: A Conversation on the Spectrum of Anxiety

Approximately 20 veterans per day die by suicide.

 Standard therapy and medications may not be enough to manage the symptoms of posttraumatic stress disorder (PTSD), but service dogs may help alleviate them.

 K9s for Warriors, the nation’s largest veteran service organization providing highly skilled service dogs to disabled veterans, has already rescued 653 veterans and 1278 dogs as of February 2021.

The PAWS Act, introduced by Florida Congressman John Rutherford, seeks to establish a competitive grant program for organizations like K9s for Warriors to pair service dogs with veterans.

Rory Diamond, the Chief Exectutive Officer of K9s for Warriors, and Maggie O’Haire, PhD, leader of the 

Organization for Human-Animal Interaction Research and Education (OHAIRE)

 research group, shared more on the effort to pair more veterans with dogs with 

: This February, the US House of Representatives reintroduced the Puppies Assisting Wounded Servicemembers (PAWS) Act, H.R. 1022, which would allocate federal funds for the training of service dogs for veterans. What kind of impact do you think this will have on the treatment of PTSD?

: Passing the PAWS Act would pave the way for allocating vital resources needed to properly train and pair more service dogs with the veterans who need them most. This type of legislation would ultimately make service dogs more accessible to more veterans as an alternative to traditional medication, while helping to restore their confidence and independence.

: Trademark symptoms of PTSD include heightened reactions, anxiety, and nightmares. Can you explain how the service dog might help alleviate these?

: PTSD service dogs are trained to perform a variety of tasks intended to alleviate PTSD symptoms. Many of these tasks are related to detecting signs of anxiety or distress and intervening. For example, a service dog can sense changes in an individualprior to a panic attack and nudge or lean against the individual to encourage them to refocus on the dog and the present space, thereby minimizing or preventing the panic attack. The service dog can also wake up a veteran from a disturbing nightmare to provide comfort. In our recent study of 134 veterans with PTSD service dogs, we found that veterans reported the most important trained service dog task was to calm/comfort from anxiety. They used this task on average 5 times every day and it was reported to help with 12 of 20 PTSD symptoms.

: In 2019, the VA reported that the suicide rate for veterans was 1.5 times the rate of non-veterans. Do you think the implementation of the PAWS Act could affect that statistic?

: Nearly 20 veterans commit suicide every day. These heroes return home feeling disconnected, unsafe, and unstable, tragically feeling like they have no other way forward. Implementing the PAWS Act would allow more of these American heroes to choose a trained service dog to help heal their invisible wounds, a proven method that’s backed by research from the US Department of Veterans Affairs (VA).

: Training these service animals can be expensive—costing almost $30,000. Do you think this price will decrease the number of trained dogs and therefore inhibit patients with PTSD from getting access?

: Despite acknowledging a national crisis exists with the alarming rate of veteran suicide, the VA has refused to take action by covering the cost of service dogs (a proven treatment method for PTSD) under the insurance benefits that veterans have earned through their military service. Upon introducing a service dog, veterans, along with their families/caregiver(s) experience a transformational improvement in quality of life, and the VA needs to take responsibility and remove the financial barrier that precludes more veterans from receiving this benefit.

: K9s For Warriors pairs dogs with those having posttraumatic stress, traumatic injury, and/or military sexual trauma. Is there an ideal patient/candidate for this service? When would this be contraindicated?

: K9s For Warriors and other service dog providers typically have an extensive application and screening process to ensure that a service dog pairing would be feasible and appropriate for both the veteran and the dog. It is important for veterans to be willing and open to bringing a new partner into their lives, including dog care, maintenance, and ongoing training. We do not yet know if there is an ideal patient/candidate for this service, but it is an ongoing area of our research. Not all veterans will be interested in having a service dog, particularly if there are allergies in the home.

: Can you share an example of a success story?

: We have more than 650 veteran graduates who can attest to the positive impact service dogs can have on both their emotional and physical state of mind. Each of these Warriors has their own success story, thanks to an unwavering bond they’ve built with their service dog battle buddy.

: Have there been any studies looking at the impact of this program? If so, could you share the results?

: Our research group at Purdue University has conducted a series of research studies in collaboration with K9s For Warriors (see publications 

). In a study of 141 veterans with PTSD, we found that those paired with service dogs showed clinically significant reductions in PTSD symptoms. The service dogs were not a cure for the disorder, but they helped make the symptoms more manageable on a daily basis.

The service dogs were also associated with broader improvements in quality of life. For example, veterans with service dogs who were employed missed work less often and reported less anxiety, depression, and greater satisfaction with their lives and social relationships. On a biological level, we also studied the stress hormone cortisol and found that veterans with service dogs had a cortisol level closer to that of healthy adults without PTSD. The evidence suggests that service dogs should not replace other services, but instead that they can provide a valuable addition to current evidence-based care. Some veterans tend to overestimate benefits and underestimate challenges, so it is also important for clinicians to work together with veterans to manage realistic expectations, thereby creating a maximally positive and productive experience for both veterans and dogs.

: Do you partner with psychiatrists/clinicians? And, if so, how?

: K9s For Warriors works in partnership with Purdue University’s College of Veterinary Medicine, and specifically Dr Maggie O’Haire (Center for the Human-Animal Bond). This partnership allows Dr O’Haire to conduct several research studies which have resulted in scientific proof of service dogs’ ability to help mitigate veteran’s symptoms of PTSD.

: How should practitioners get in contact with service dog programs?

: Practitioners can advise their (post 9/11) veteran patients to fill out an application with K9s For Warriors to be considered for our program: 

https://www.k9sforwarriors.org/warrior-application-survey

To see more on this topic, see Dr O’Haire’s video, 

1. K9s for Veterans. Updated February 2021. Accessed March 30, 2021. 

2. Purdue University. Study shows physiological and behavioral benefits may be experienced by veterans with PTSD who have service dogs. News release. June 12, 2018. Accessed March 30, 2021. 

https://www.k9sforwarriors.org/sites/default/files/180612%20OHairePTSD_final_06_08.pdf

3. Rutherford, Pappas, Waltz, Lawson, Stivers Reintroduce PAWS Act. News release. March 3, 2021. Accessed March 30, 2021. 

https://rutherford.house.gov/media/press-releases/rutherford-pappas-waltz-lawson-stivers-reintroduce-paws-act

Service animals can help save veterans’ lives.

Rx Dog Therapy: How Man’s Best Friend Helps Veterans With PTSD

Maggie O'Haire, PhD, shares how service dogs can help alleviate posttraumatic stress disorder (PTSD) symptoms, like by detecting distress signals and waking the veteran up during a nightmare. 

, introduced by Florida Congressman John Rutherford, seeks to establish a competitive grant program for organizations like K9s for Warriors to pair service dogs with veterans. 

 research group and an associate professor of Human-Animal Interaction at Purdue University.

These service animals are improving veteran lives...

Service Dogs for Veterans With PTSD

Jessica Peirce, PhD, discusses how people coping with addiction rarely receive treatment for posttraumatic stress disorder, or any trauma care, despite the benefits it may reap. 

is the Interim Director at the Addiction Treatment Services & Center for Addiction and Pregnancy, and associate professor of psychiatry and behavioral sciences at Johns Hopkins University.

1 in 6 people with opioid use disorder experience a new traumatic event every month, but no evidence-based treatment for trauma. 

Treating Trauma and Addiction Simultaneously

Female veterans with posttraumatic stress disorder (PTSD), especially younger women who are non-white, have an increased risk of developing heart disease.

Findings such as these were presented Friday, November 13, through Tuesday, November 17, at the American Heart Association’s Scientific Sessions 2020.

The presenter was Ramin Ebrahimi, MD, professor of medicine at the University of California, Los Angeles, and director of interventional cardiovascular research and co-director of the Cardiac Catheterization Laboratory at the Greater Los Angeles VA (Veterans Affairs) Medical Center.

“Previous research has linked PTSD to higher risks of ischemic heart disease, including heart attacks and heart pain or angina. However, most of those studies have been in men,” Ebrahimi said to the press.

To conduct the study, Ebrahimi evaluated medical records of female veterans cared for at all US Veterans Health Administration centers between 2000 and the end of 2017. The research team identified nearly 130,000 female veterans with PTSD and nearly 260,000 without the mental health condition. They assessed records for annual exams, emergency room visits and other exams/hospitalizations for new diagnoses of coronary artery disease, angina, or heart attacks.

According to Ebrahimi, they found that women with PTSD had a 44% higher risk of developing ischemic heart disease compared to those without PTSD, and the increased risk was more prominent in younger women, especially those younger than 40 years old (72%).

The increased heart disease risk among female veterans with PTSD was also higher in racial and ethnic minorities, including Black women, non-white women from other racial backgrounds and women of Hispanic and Latinx ethnicity, compared with white female veterans.

“Our results suggest that health care professionals should consider more routine and earlier screening for cardiovascular disorders in women with PTSD,” Ebrahimi said.

1. American Heart Association. Women veterans with PTSD have higher rate of heart disease. News release. November 9, 2020. Accessed November 13, 2020. 

https://www.eurekalert.org/pub_releases/2020-11/aha-wvw110220.php

Non-white veteran women of color may be at greater risk of developing heart disease, according to research.  

Female Veterans with PTSD at Higher Risk of Heart Disease

more than half of gay, lesbian, and bisexual individuals who abuse alcohol or tobacco also have a co-occurring psychiatric disorder, whereas only one-third of heterosexual individuals have the same correlation.

“The degree of disparities in alcohol, tobacco and other psychiatric disorders by sexual identity was very surprising,” Rebecca Evans-Polce, assistant research scientist at the University of Michigan School of Nursing and first author of the study, said to the press. “The differences for women are more striking.”

Previous studies have demonstrated that LGBTQ+ individuals are at greater risk for both substance use disorders and psychiatric disorders. Evans-Polce noted that the new study, which gathered data from 35,796 responses from the National Epidemiologic Survey on Alcohol and Related Conditions, is 1 of the few to examine this risk.

An interesting finding of note is the prevalent comorbidities for bisexual women. When compared to heterosexual women, bisexual women were found much more likely to have an anxiety disorder (32.5% bisexual, 16% heterosexual), mood disorder (35% bisexual, 15% heterosexual), and post-traumatic stress disorder (21% bisexual, 6% heterosexual). According to the data, 63% of bisexual women misusing tobacco also had an anxiety disorder, mood disorder, or PTSD. In contrast, only 46% of heterosexual women with a tobacco use disorder also had a psychiatric issue.

Bisexual individuals overall were 4 times more likely to have PTSD than heterosexual individuals.

The reason for this association is unconfirmed, but researchers suspect discrimination and trauma may be to blame. Sexual orientation discrimination, the number of stressful life events, and the number of adverse childhood experiences were strongly associated with greater risk of comorbidities.

Researchers determined that the data demonstrates a need for integrated substance use and mental health prevention and treatment programs, particularly for individuals who identify as sexual minorities. Additionally, more research is needed to comprehend why data repeatedly points to such a high risk for bisexual women.

1. Evans-Polce RJ, Kcomt L, Veliz PT, Boyd CJ, et al. Alcohol, Tobacco, and Comorbid Psychiatric Disorders and Associations With Sexual Identity and Stress-Related Correlates. 

2. University of Michigan. Sexual minorities, especially women, who misuse substances more likely to have psychiatric disorders. News release. 

https://medicalxpress.com/news/2020-11-sexual-minorities-women-misuse-substances.html

Sexual minorities with alcohol and tobacco addictions are at a higher risk for comorbid psychiatric disorders, bisexual women in particular.

LGBTQ+ Individuals who Abuse Substances Are More Likely to Have Psychiatric Disorders

If you were to poll physicians and ask which specialty usually takes the lead in the management of chronic pain, no doubt an overwhelming majority would say anesthesiology, with a smaller number saying neurology and physiatry. However, probably few would say psychiatry.

It is odd considering the recent revision of the 

 by the International Association for the Study of Pain, the leading worldwide organization for medical professionals involved in the field of pain: “Pain is always a subjective experience that is influenced to varying degrees by biological, psychological, and social factors.”

 This appears to be almost precisely with what psychiatry deals.

We already know that there is a high degree of comorbidity between 

 with chronic pain and, although it is commonly thought that the mental disorders are always secondary to the pain, research has shown that pain is a common presenting symptom of these disorders.

The papers in this Special Report discuss 2 other problems that frequently occur in those with chronic pain: 

 (PTSD). We have known about the relationship between sleep disorders and chronic pain for years; however, the relationship between pain and PTSD is a more recent finding.

As with depressive and anxiety disorders, it is usually thought that if a sleep disorder is present in a person with chronic pain, the sleep issue is always secondary to the pain. However, this oversimplifies the relationship. The interaction between pain and sleep disorders is often a 2-way street, with each exacerbating the other. Both the pain and the sleep disorder need to be addressed.

Of course, the presence of any type of pain can impair sleep. Patients with peripheral diabetic neuropathic pain often report worse pain in their lower extremities during the night when they are trying to sleep. Those who suffer from complex regional pain syndrome in their lower extremities may complain that it is it painful to have sheets touch their skin due to allodynia, in which stimuli that do not usually cause pain do so. Patients with back pain often report problems with sleep due to pain although, curiously, laying down is the position they usually find most comfortable. In fact, if the pain is worse lying down, it is considered a red flag indicative of serious underlying pathology.

Similarly, disruption in normal sleep cycles can cause pain. More than 45 years ago, research found disruptive sleep in some healthy individuals precipitated the symptoms of fibromyalgia and resulted in widespread pain.

There are few studies on the treatment of comorbid pain and sleep disorders. Although both are commonly treated with medications, there is limited research on using pharmacologic agents when both problems are present. Most of the studies have looked at pregabalin in patients with fibromyalgia.

Opioids and benzodiazepines, medications that are frequently prescribed for patients with chronic pain, may actually exacerbate pain because they can cause hyperalgesia (eg, lower pain threshold). These agents can also exacerbate sleep disorders because of their disruption of normal sleep architecture. Sadly, many lay people and medical professionals mistakenly believe that the sedative side effects of these medications mean they will be beneficial for sleep.

There is much less research on chronic pain and PTSD, although there has been a growing interest in the past few years. 

A limiting factor of the data is that much of the research involves veterans. Due to the nature of our recent wars, many veterans suffer from painful injuries caused by explosions. They frequently suffer from traumatic brain injuries (TBI) of varying severity. In fact, both pain and sleep disorders have both been associated with TBI.

 Of course, few civilians who suffer PTSD have similar experiences, so the role TBI may play in the development of comorbid PTSD and chronic pain remains to be determined. 

In addition, research has shown that PTSD may not only be associated with both pain and sleep disorders, but also play a role in acute pain becoming chronic pain.

Since we have yet to identify a markedly efficacious treatment for PTSD, adding chronic pain as a factor further complicates care decisions. Furthermore, although there has been much speculation as to which factors predispose people to develop PTSD and chronic pain separately, we still have no final answer, and we have limited ability to predict who is at increased likelihood for developing both.

For all 3 problems—PTSD, sleep disorders, and chronic pain—psychologically based therapies appear to be among the most promising treatments. They also do not carry the same risks of exacerbating another condition as do medications.

Since psychiatrists often treat PTSD and even sleep, there is little doubt they will see patients with comorbid chronic pain. Unless psychiatrists also are knowledgeable about pain and its management, we will not be able to provide optimal care for our patients.

 is in private practice in Philadelphia.

This article was originally posted on October 21, 2020, and has since been updated. Scroll down for the 

 of the full print issue in which it appeared. -Ed

The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises.

2. Moldofsky H, Scarisbrick P, England R, et al. Musculoskeletal symptoms and non-REM sleep disturbance in patients with “fibrositis syndrome” and health subjects. 

3. Husak AK, Bair MJ. Chronic pain and sleep disturbances: a pragmatic review of their relationships, comorbidities, and treatments. 

4. Lavigne G, Khoury S, Chauny JM, et al. Pain and sleep in post-concussion/mild traumatic brain injury. 

5. Burns JW, Janssen, Lillis T, et al. The transition from acute to persistent pain: the identification of distinct trajectories among women presenting to an emergency department. 

Pain may not often be considered within the realm of psychiatry; however, chronic pain's relationships with sleep disorders and PTSD make it an issue psychiatrists can—and should—address.  

Psychiatry’s Role in the Management of Chronic Pain

The US Food and Drug Administration (FDA) granted a De Novo clearance to a prescription Apple watch and iPhone app meant to improve sleep quality for those with nightmare disorders or posttraumatic stress disorder-related nightmares.

 uses the watch’s sensors to track the user’s heart rate and movement as they sleep. A baseline profile is created for the patient within 1 to 2 nights of sleep. In this short time frame, the learning algorithm will spot heart rate of movement abnormalities likely caused by a nightmare. If the app senses a disturbance, the Apple watch will vibrate enough to interrupt the dream, but not enough to fully wake them up and disturb their sleep cycle.

“Sleep is an essential part of a person’s daily routine,” Carlos Peña, PhD, director of the Office of Neurological and Physical Medicine Devices in the FDA’s Center for Devices and Radiological Health, said to the press. “However, certain adults who have a nightmare disorder or who experience nightmares from PTSD are not able to get the rest they need. Today’s authorization offers a new, low-risk treatment option that uses digital technology in an effort to provide temporary relief from sleep disturbance related to nightmares.”

Data submitted to the FDA included information from a 30-day trial of 70 patients who were randomly assigned to receive either the NightWare app or a placebo app with no vibrations. While both groups self-reported improved sleep quality, the benefit was greater for those provided with the Nightware product.

Further trials are being conducted, one of which hopes to include 240 patients from several Department of Veterans Affairs hospitals. It is projected to finish in the second half of 2021.

“NightWare was founded and built to support veterans and active duty service members who have so unselfishly given of themselves to preserve our freedoms, and suffer emotional, physical and mental distress as a consequence of severe nightmares,” NightWare CEO Grady Hannah said in a statement. “Helping our current and past military members and all people with this condition is NightWare’s mission and we are excited to introduce this first and only therapeutic for nightmares. The use of the NightWare Therapeutic Platform provides an effective treatment for clinically significant nightmares; avoids drug side-effects; and reduces the need for time intensive and often-unavailable psychological therapy sessions.”

The NightWare therapy is currently available on a limited basis through physician recommendation, but will hopefully launch in the early months of 2021. It will require a prescription and is intended for use among adults aged 22 years or older. It is not recommended for patients who sleepwalk or have violent episodes during nightmares. It is also not recommended as a standalone treatment for PTSD.

1. NightWare. We won’t rest until those with PTSD can. Accessed November 13, 2020. 

2. Muoio D. FDA grants De Novo clearance to prescription Apple Watch app for nightmare disorder. 

https://www.mobihealthnews.com/news/fda-grants-de-novo-clearance-prescription-apple-watch-app-nightmare-disorder

A new prescription smartwatch app may improve sleep quality for those with nightmare disorders. 

PTSD