Treatment Of Nightmares Research Articles

P-115 - Clonidine treatment of nightmares in PTSD

Over 2 million US service members have now deployed to the Iraq and Afghanistan conflicts. Providers have consequently observed steep increases in mental health service use among these veterans. Dysregulation of the autonomic nervous system is thought to explain the physiological changes in patients with PTSD. This is the report of a patient whose nightmares were successfully treated with clonidine. Mr. F, a 48 years old man who developed PTSD symptoms after fighting in the Bosnian war for 15 months. He reported witnessing the loss of his family members and other relatives He was treated with venlafaxine XR 225 mg po q daily and olanzapine 10 mg po q daily without any relieve of his nightmares. He was later started on clonidine 0.1 mg po qhs. Within 2 weeks of starting clonidine, he reported improvement in the severity and duration of his nightmares and improved quality of his sleep. Clonidine a centrally acting alpha-agonist agent used to treat hypertension stimulates alpha-adrenoreceptors in the brainstem. This action results in reduced sympathetic outflow from the central nervous system. We hypothesize that this central mechanism of action is why clonidine may be more effective in treating nightmares in PTSD. Although, clonidine should be considered as an alternative in the treatment of nightmares among patients with PTSD, more clinical studies are needed to determine when to use clonidine.

Imagery rescripting and exposure group treatment of posttraumatic nightmares in Veterans with PTSD

This study details results of an open trial of a group psychological treatment for Veterans with posttraumatic stress disorder (PTSD) and chronic posttraumatic nightmares called “Imagery Rescripting and Exposure Therapy” (IRET). IRET is a variant of a successful imagery rescripting treatment for civilian trauma-related nightmares that was modified to address the needs of the Veteran population. Thirty-seven male U.S. Veterans with PTSD and nightmares attended 6 multicomponent group sessions. Findings indicated that the intervention significantly reduced frequency of nightmares and PTSD severity, as well as increased hours of sleep. Unlike the few open trials examining treatment of nightmares in Veterans, effect sizes in this study were similar to those that have been found in the civilian randomized controlled trial. These preliminary findings suggest that a nightmares treatment can be adapted to successfully reduce distress associated with combat Veterans’ chronic nightmares. Clinical and research implications are discussed.

Effectiveness of Risperidone for the Treatment of Nightmares in Veterans With Posttraumatic Stress Disorder

Effectiveness of Risperidone for the Treatment of Nightmares in Veterans With Posttraumatic Stress Disorder

Nightmare Reduction in a Vietnam Veteran Using Imagery Rehearsal Therapy

Following exposure to traumatic events, approximately 19% of combat veterans develop posttraumatic stress disorder. One of the main symptoms of this mental illness is reexperiencing the trauma, which is commonly expressed in the form of chronic trauma-related nightmares. In these patients, nightmares can fragment sleep, decrease sleep quality, and even cause fear about going to sleep. One promising psychological treatment for chronic nightmares is imagery rehearsal therapy. Imagery rehearsal therapy presumes that nightmares are a learned behavior and that activating the visual imagery system may facilitate emotional processing of the trauma. This treatment involves deliberately rewriting a nightmare and mentally rehearsing images from the newly rescripted scenario while awake. Imagery rehearsal therapy has been found to reduce nightmares and associated distress. We present a case study demonstrating the use of imagery rehearsal therapy in a Vietnam-era veteran with posttraumatic stress disorder and chronic nightmares. Nightmares were considerably reduced and the quality of sleep greatly improved after treatment.

Prazosin treatment of trauma nightmares and sleep disturbance in soldiers deployed in Iraq

Trauma nightmares and sleep disturbance impair combat soldiers' functioning. The alpha-1 adrenoreceptor antagonist prazosin has been demonstrated effective for these symptoms in Vietnam veterans. Thirteen soldiers seeking relief from distressing trauma nightmares impairing military function in northern Iraq in 2006 received prazosin alone or in combination with other psychotropics. Mean prazosin dose was 4.1 (SD = 2.2) mg before bed. Six soldiers improved markedly and 3 moderately on the Clinical Global Impression of Change Ratings of distressing dreams decreased from an average of 7.0 (SD = 0.7) to 2.9 (SD = 3.0, p < .001) and those of disturbed sleep from 6.7 (SD = 0.9) to 3.7 (SD = 2.4, p < .001). Prazosin appears effective and well tolerated in the desert warfare environment.

Treatment of nightmares in the context of posttraumatic stress disorder

Nightmares are a common feature of posttraumatic stress disorder (PTSD) and are frequently resistant to treatment. Two emerging treatments for nightmares are pharmacotherapy with prazosin and psychotherapy using imagery rehearsal (IR). A case illustration demonstrates the application of these treatments with a client suffering from chronic, severe PTSD. The case illustrates the use of these strategies for managing PTSD-related nightmares, as well as the novel approach of scheduled awakenings following relapse.

Imagery rehearsal for posttraumatic nightmares: A randomized controlled trial

One hundred twenty-four male Vietnam War veterans with chronic, severe posttraumatic stress disorder (PTSD) were randomly assigned to imagery rehearsal (n = 61) or a credible active comparison condition (n = 63) for the treatment of combat-related nightmares. There was pre-post change in overall sleep quality and PTSD symptoms for both groups, but not in nightmare frequency. Intent-to-treat analyses showed that veterans who received imagery rehearsal had not improved significantly more than veterans in the comparison condition for the primary outcomes (nightmare frequency and sleep quality), or for a number of secondary outcomes, including PTSD. Six sessions of imagery rehearsal delivered in group format did not produce substantive improvement in Vietnam War veterans with chronic, severe PTSD. Possible explanations for findings are discussed.

Cognitive-Behavioral Self-Help Treatment for Nightmares: A Randomized Controlled Trial

Background: Several cognitive-behavioral techniques are effective in reducing nightmare frequency, but the therapeutic factor (e.g. cognitive restructuring, systematic desensitization) remains unclear. The aim of this study was to compare the nightmare treatments imagery rehearsal therapy (IRT), exposure, and recording (keeping a diary) – in a self-help format – with a waiting list. Methods: Participants were recruited through a Dutch nightmare website. After completion of the baseline questionnaires, 399 participants were randomly assigned to a condition, received a 6-week self-help treatment (or were placed on the waiting list), and filled out the post-treatment measurements 11 weeks after baseline. Results: Compared to the waiting list, IRT and exposure were effective in ameliorating nightmare frequency and distress, subjective sleep quality, anxiety (after imagery rehearsal), and depression (after exposure; Δd = 0.25–0.56). Compared to recording, IRT reduced nightmare frequency while exposure reduced nightmare distress (Δd = 0.20–0.30; p < 0.05). The recording condition was more effective compared to the waiting list in ameliorating nightmare frequency, nightmare distress, and subjective sleep quality (Δd = 0.19–0.28; p < 0.05). IRT had a more rapid reduction on the diary compared to exposure and recording. Conclusions: IRT and exposure appear equally effective in ameliorating nightmare complaints. Exposure to nightmare imagery may function as the crucial therapeutic factor; however, cognitive restructuring may be a useful addition to increase immediate effects.

Imagery rehearsal therapy: An emerging treatment for posttraumatic nightmares in veterans.

Imagery rehearsal therapy: An emerging treatment for posttraumatic nightmares in veterans.

Best Practice Guide for the Treatment of Nightmare Disorder in Adults

Prazosin is recommended for treatment of Posttraumatic Stress Disorder (PTSD)-associated nightmares. Level A. Image Rehearsal Therapy (IRT) is recommended for treatment of nightmare disorder. Level A. Systematic Desensitization and Progressive Deep Muscle Relaxation training are suggested for treatment of idiopathic nightmares. Level B. Venlafaxine is not suggested for treatment of PTSD-associated nightmares. Level B. Clonidine may be considered for treatment of PTSD-associated nightmares. Level C. The following medications may be considered for treatment of PTSD-associated nightmares, but the data are low grade and sparse: trazodone, atypical antipsychotic medications, topiramate, low dose cortisol, fluvoxamine, triazolam and nitrazepam, phenelzine, gabapentin, cyproheptadine, and tricyclic antidepressants. Nefazodone is not recommended as first line therapy for nightmare disorder because of the increased risk of hepatotoxicity. Level C. The following behavioral therapies may be considered for treatment of PTSD-associated nightmares based on low-grade evidence: Exposure, Relaxation, and Rescripting Therapy (ERRT); Sleep Dynamic Therapy; Hypnosis; Eye-Movement Desensitization and Reprocessing (EMDR); and the Testimony Method. Level C. The following behavioral therapies may be considered for treatment of nightmare disorder based on low-grade evidence: Lucid Dreaming Therapy and Self-Exposure Therapy. Level C No recommendation is made regarding clonazepam and individual psychotherapy because of sparse data.

Prévalence, corrélats et traitements des cauchemars chez les enfants

Few studies have been conducted on nightmares in children. This article presents a review of the literature on the prevalence, correlates and treatment of nightmares while highlighting key methodological issues. Studies indicate that almost half of children experience nightmares and that the presence of nightmares is related to different variables including anxiety, stress, behavioral problems and other sleep disorders. Finally, there is very little information on the treatment of nightmares in children, but promising results have been obtained with techniques based on imagery rehearsal therapy. Based on this review, future directions for research are suggested.

Cognitive‐behavioral treatment for chronic nightmares in trauma‐exposed persons: assessing physiological reactions to nightmare‐related fear

Cognitive-behavioral treatments (CBTs) that target nightmares are efficacious for ameliorating self-reported sleep problems and psychological distress. However, it is important to determine whether these treatments influence objective markers of nightmare-related fear, because fear and concomitant physiological responses could promote nightmare chronicity and sleep disturbance. This randomized, controlled study (N=40) assessed physiological (skin conductance, heart rate, facial electromyogram) and subjective (displeasure, fear, anger, sadness, arousal) reactions to personally relevant nightmare imagery intended to evoke nightmare-related fear. Physiological assessments were conducted at pretreatment as well as 1-week, 3-months, and 6-months posttreatment. Results of mixed effects analysis of variance models suggested treatment reduced physiological and subjective reactions to nightmare imagery, gains that were generally maintained at the 6-month follow-up. Potential implications are discussed.

Effectiveness of Imagery Rehearsal Therapy for the Treatment of Combat-Related Nightmares in Veterans

Imagery Rehearsal Therapy (IRT) has been shown to be efficacious in reducing nightmares, but the treatment has not been well-studied in veterans. The effectiveness of IRT was assessed from a chart review of veterans seeking outpatient treatment for chronic, trauma-related nightmares. Of those offered IRT, veterans who completed a full course of treatment for PTSD in the past year were more likely to initiate treatment. However, completion of IRT was not related to previous treatment, demographic variables, or nightmare severity reported at the first treatment session. Treatment completers reported significant reductions in nightmare frequency and intensity, severity of insomnia, and subjective daytime PTSD symptoms. Insomnia and PTSD symptoms, on average, were below clinical cutoffs following treatment, and 23% of patients showed a complete treatment response (≤ 1 nightmare/week). Findings suggest IRT may be an effective short-term treatment for nighttime and daytime PTSD symptoms among veterans who complete a full course of treatment.

A combined group treatment for nightmares and insomnia in combat veterans: A pilot study

Insomnia and nightmares are hallmarks of posttraumatic stress disorder (PTSD). Sleep disturbances in PTSD negatively impact clinical course and functioning. In this open clinical trial, the preliminary effects of a combined treatment for insomnia and nightmares in combat veterans with PTSD were assessed. Ten combat veterans participated in a 10-session group treatment combining cognitive-behavioral therapy for insomnia with exposure, rescripting, and relaxation therapy. Participants maintained daily sleep and dream diaries and completed self-report measures of sleep quality and PTSD symptoms pre- and posttreatment. Participants reported improvements in sleep and nightmares following treatment. Future research using controlled designs to evaluate this treatment is warranted.

Preliminary Findings Concerning the Use of Prazosin for the Treatment of Posttraumatic Nightmares in a Refugee Population

Prazosin, a centrally active alpha-1 adrenergic receptor antagonist, has reduced nightmares and sleep disturbances in placebo-controlled studies involving patients with combat and civilian related posttraumatic stress disorder (PTSD). In this retrospective chart review, we analyzed data from 23 refugees diagnosed with chronic PTSD who were treated with prazosin. The recurrent distressing dreams item of the Clinician Administered PTSD Scale (CAPS) was used to quantify nightmare severity. A Clinical Global Impressions-Change (CGI-C) score assessed change in overall PTSD severity exclusive of nightmares. Using a paired-samples t-test, we found that CAPS scores decreased significantly (p <0.0005) from baseline after 8 weeks of treatment with a stable dose of prazosin. Overall PTSD severity was "markedly improved" in 6 patients, "moderately improved" in 11 patients, and "minimally improved" in 6 patients. These data provide preliminary support for the use of prazosin in targeting reduction of trauma-related nightmares and promoting improvement of global clinical status within an international sample of severely traumatized refugee patients.

Prazosin Treatment of an Adolescent with Posttraumatic Stress Disorder

Journal of Child and Adolescent PsychopharmacologyVol. 19, No. 5 Letters to the EditorPrazosin Treatment of an Adolescent with Posttraumatic Stress DisorderJeffrey R. Strawn, Melissa P. DelBello, and Thomas D. GeraciotiJr.Jeffrey R. StrawnDepartment of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, Ohio.Department of Pediatrics, Division of Psychiatry, Cincinnati Children's Hospital Medical Center, Ohio.Search for more papers by this author, Melissa P. DelBelloDepartment of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, Ohio.Department of Pediatrics, Division of Psychiatry, Cincinnati Children's Hospital Medical Center, Ohio.Search for more papers by this author, and Thomas D. GeraciotiJr.Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, Ohio.Search for more papers by this authorPublished Online:30 Oct 2009https://doi.org/10.1089/cap.2009.0043AboutSectionsView articleView Full TextPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Prazosin Treatment of an Adolescent with Posttraumatic Stress Disorder." , 19(5), pp. 599–600FiguresReferencesRelatedDetailsCited byPsychopharmacological Treatment of Pediatric PTSDPsychiatric Annals, Vol. 50, No. 5Pediatric Post-Traumatic Stress DisorderChildhood Stress and TraumaUse of Prazosin for Pediatric PTSD-Associated Nightmares and Sleep Disturbances: A Retrospective Chart Review28 July 2017 | Neurology and Therapy, Vol. 6, No. 2Prazosin in Children and Adolescents With Posttraumatic Stress Disorder Who Have NightmaresJournal of Clinical Psychopharmacology, Vol. 37, No. 1Sleep in Adolescents with Psychiatric Disorders22 September 2016Pharmacologic Considerations for Youth with Posttraumatic Stress DisorderJournal of the Korean Academy of Child and Adolescent Psychiatry, Vol. 28, No. 1Pharmacological Treatment for Children and Adolescents with Trauma-Related Disorders14 February 2017ICD in Children and Youth21 July 2017Treatment-refractory posttraumatic stress disorder (TRPTSD): a review and framework for the futureProgress in Neuro-Psychopharmacology and Biological Psychiatry, Vol. 70Clinical Tools for the Prevention and Treatment of Childhood and Adolescent PTSD30 January 2015 | Current Treatment Options in Psychiatry, Vol. 2, No. 1The effects of stress exposure on prefrontal cortex: Translating basic research into successful treatments for post-traumatic stress disorderNeurobiology of Stress, Vol. 1Expanded Usage of Prazosin in Pre-Pubertal Children with Nightmares Resulting from Posttraumatic Stress Disorder20 October 2014 | Journal of Child and Adolescent Psychopharmacology, Vol. 24, No. 8Psychological and Pharmacologic Treatment of Youth with Posttraumatic Stress DisorderChild and Adolescent Psychiatric Clinics of North America, Vol. 23, No. 2Longitudinal Outcomes for Victims of Child Abuse10 January 2013 | Current Psychiatry Reports, Vol. 15, No. 2Psychopharmacology of Pediatric Anxiety Disorders28 March 2013Treatment of Childhood Sexual Abuse: An Updated Review26 September 2012 | Current Psychiatry Reports, Vol. 14, No. 6Prazosin Treatment of Nightmares and Sleep Disturbances Associated with Posttraumatic Stress Disorder: Two Adolescent Cases19 October 2012 | Journal of Child and Adolescent Psychopharmacology, Vol. 22, No. 5Treatment of Nightmares With Prazosin: A Systematic ReviewMayo Clinic Proceedings, Vol. 87, No. 9Successful Treatment of Posttraumatic Stress Disorder with Prazosin in a Young Child24 November 2011 | Annals of Pharmacotherapy, Vol. 45, No. 12Psychopharmacologic treatment of traumatized youthCurrent Opinion in Pediatrics, Vol. 22, No. 5 Volume 19Issue 5Oct 2009 InformationCopyright 2009, Mary Ann Liebert, Inc.To cite this article:Jeffrey R. Strawn, Melissa P. DelBello, and Thomas D. GeraciotiJr..Prazosin Treatment of an Adolescent with Posttraumatic Stress Disorder.Journal of Child and Adolescent Psychopharmacology.Oct 2009.599-600.http://doi.org/10.1089/cap.2009.0043Published in Volume: 19 Issue 5: October 30, 2009PDF download

Prozosin for the Treatment of Posttraumatic Stress Disorder-Related Nightmares in an Adolescent Male

Journal of Child and Adolescent PsychopharmacologyVol. 19, No. 4 Letters to the EditorProzosin for the Treatment of Posttraumatic Stress Disorder-Related Nightmares in an Adolescent MaleLisa A. Fraleigh, Venkatesh D. Hendratta, Julian D. Ford, and Daniel F. ConnorLisa A. FraleighSearch for more papers by this author, Venkatesh D. HendrattaSearch for more papers by this author, Julian D. FordSearch for more papers by this author, and Daniel F. ConnorSearch for more papers by this authorPublished Online:24 Aug 2009https://doi.org/10.1089/cap.2009.0002AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Prozosin for the Treatment of Posttraumatic Stress Disorder-Related Nightmares in an Adolescent Male." , 19(4), pp. 475–476FiguresReferencesRelatedDetailsCited byDraft Genome Sequence of the Prazosin-Degrading Bacillus sp. Strain PR5, Isolated from a River Receiving Hospital and Urban Wastewater in MalaysiaMicrobiology Resource Announcements, Vol. 10, No. 11Psychopharmacological Treatment of Pediatric PTSDPsychiatric Annals, Vol. 50, No. 5Pediatric Post-Traumatic Stress DisorderPrazosin in Children and Adolescents With Posttraumatic Stress Disorder Who Have NightmaresJournal of Clinical Psychopharmacology, Vol. 37, No. 1Sleep in Adolescents with Psychiatric Disorders22 September 2016Pharmacological Treatment for Children and Adolescents with Trauma-Related Disorders14 February 2017ICD in Children and YouthAn Update on Posttraumatic Stress Disorder in Children and Adolescents2 July 2014 | Clinical Pediatrics, Vol. 54, No. 6The effects of stress exposure on prefrontal cortex: Translating basic research into successful treatments for post-traumatic stress disorderNeurobiology of Stress, Vol. 1Expanded Usage of Prazosin in Pre-Pubertal Children with Nightmares Resulting from Posttraumatic Stress Disorder Presenters: Revital Racin, Christopher Bellonci, and Discussant: Barbara J. Coffey20 October 2014 | Journal of Child and Adolescent Psychopharmacology, Vol. 24, No. 8Psychological and Pharmacologic Treatment of Youth with Posttraumatic Stress DisorderChild and Adolescent Psychiatric Clinics of North America, Vol. 23, No. 2The Role of Guanfacine as a Therapeutic Agent to Address Stress-Related Pathophysiology in Cocaine-Dependent IndividualsLongitudinal Outcomes for Victims of Child Abuse10 January 2013 | Current Psychiatry Reports, Vol. 15, No. 2Psychopharmacology of Pediatric Anxiety Disorders28 March 2013Prazosin Treatment of Nightmares and Sleep Disturbances Associated with Posttraumatic Stress Disorder: Two Adolescent Cases Olumide O. Oluwabusi, Karim Sedky, and David S. Bennett19 October 2012 | Journal of Child and Adolescent Psychopharmacology, Vol. 22, No. 5Treatment of Nightmares With Prazosin: A Systematic ReviewMayo Clinic Proceedings, Vol. 87, No. 9 Volume 19Issue 4Aug 2009 InformationCopyright 2009, Mary Ann Liebert, Inc.To cite this article:Lisa A. Fraleigh, Venkatesh D. Hendratta, Julian D. Ford, and Daniel F. Connor.Prozosin for the Treatment of Posttraumatic Stress Disorder-Related Nightmares in an Adolescent Male.Journal of Child and Adolescent Psychopharmacology.Aug 2009.475-476.http://doi.org/10.1089/cap.2009.0002Published in Volume: 19 Issue 4: August 24, 2009PDF download

Post-Traumatic Stress Disorder Nightmares and Sleep Disturbance in Iraq War Veterans: A Feasible and Promising Treatment Combination

A substantial proportion of returnees from the Iraq war have significant psychological symptoms related to war zone exposure, including high rates of post-traumatic stress disorder (PTSD), nightmares, and sleep disturbances. This pilot investigation examined the feasibility and efficacy of a promising cognitive-behavioral treatment (CBT) for nightmares, Imagery Rehearsal, combined with CBT for insomnia. Seven veterans completed treatment and showed promising pre-post effects regarding nightmare frequency, sleep quality, and PTSD. This report further examined the content of participants' nightmares, changes made during treatment, and potentially important modifying variables of treatment outcome. Those with redeployment fears, guilt due to perpetration issues, or traumatic brain injuries may receive some but not full benefits of the treatment.

Epidemiological study of nightmare and sleep paralysis among Japanese adolescents

In this study, we have elucidated the prevalence of and factors associated with nightmares and sleep paralysis in Japanese adolescents. We conducted a survey of first-year senior high school students by employing self-administered questionnaires about nightmare and sleep paralysis. All the subjects were first-year students (1164) from three private high schools. The responses of the remaining 916 subjects (568 boys and 348 girls) were considered valid. We found that in Japanese adolescents, the current prevalence of nightmares is 27.4%, and that of sleep paralysis is 7.2%. The lifetime prevalence of sleep paralysis is 30.4%. Results of the multiple logistic regression analysis revealed factors associated with nightmare and sleep paralysis. With regard to nightmares, the adjusted odds ratios for “female gender”, “bedtime after 12 am”, “wake up time before 6:30 am”, “difficulty maintaining sleep or early morning awakening”, “daily tea drinking”, “poor mental health”, and “presence of sleep paralysis” were significantly high. With regard to sleep paralysis, the adjusted odds ratios for “30 min or more of sleep latency”, “less than 6 h of sleep duration”, “presence of naps”, and “presence of nightmares” were significantly high. These results reveal that nightmare and sleep paralysis are prevalent problems among adolescents as well as adults. Moreover, these conditions are associated with factors of mental health and insomnia, and that these factors are associated with each other. Such associations should be considered in the prevention and treatment of nightmares and sleep paralysis among adolescents.

Tracing the Flow of Knowledge

Passive diffusion of new medical innovations is an important mechanism by which knowledge transitions from research to clinical practice. Preliminary evidence has emerged about the effectiveness of the alpha(1)-adrenergic blocker prazosin hydrochloride in the treatment of nightmares and hyperarousal among patients with posttraumatic stress disorder (PTSD). This treatment has been neither widely accepted nor the subject of active dissemination efforts, and its efficacy was discovered in a discrete geographic location. To evaluate the pace and reach of the passive dissemination of a promising technology within a national health care system. Geographic surveillance data study. Academic research. We tracked the use of prazosin in the treatment of patients diagnosed as having PTSD in the Department of Veterans Affairs during fiscal years 2004 (n = 203 414) and 2006 (n = 319 670). The percentage of patients diagnosed as having PTSD who received a prescription for prazosin. Whereas 37.6% of patients with PTSD treated within the Veterans Affairs Puget Sound Health Care System, Tacoma, Washington, in 2004 were prescribed prazosin, only 18.2% were treated with prazosin at medical centers up to 499 miles (to convert miles to kilometers, multiply by 1.6) away, 6.7% at centers 500 to 999 miles away, 4.0% at centers 1000 to 2499 miles away, and 1.9% at centers 2500 miles away or farther. Adjusting for patient characteristics, patients with PTSD treated up to 499 miles from Puget Sound were about 49% less likely in 2006 and about 63% less likely in 2004 to be prescribed prazosin than their counterparts treated within Puget Sound, while those who were treated 2500 miles away or farther were about 94% less likely in 2006 and about 97% less likely in 2004 to be treated with prazosin than patients within Puget Sound. Passive diffusion of a new treatment can be rapid in the immediate area in which it is developed, but the geographic gradient of use seems to be steep and enduring even when cost and organizational barriers are minimal.