PROPRANOLOL DOSES TO REDUCE PTSD SYMPTOMS

As I mentioned in a previous blog entitled: ” Research using propranolol to treat PTSD and my experience with using propranolol,” when I was reviewing the research regarding the use of propranolol in treating PTSD I realized that the results did not show that propranolol helped to reduce symptoms related to PTSD. In reviewing these studies I often could not find doses that were used and when I could they were low in the 20-40 mg range except for one study that used 240 mg. I wondered if the lack of positive response was related to the doses used and the fact that the doses were not individually titrated until a positive response occurred. For this reason I began to record the doses of propranolol I prescribed for the 68 of my patients where I was targeting PTSD symptoms.

The average dose of propranolol that I prescribed for the 68 patients I reviewed was 357.87 mg. I then removed 17 patients who represented the lowest and highest doses and the average was reduced to 314.80 mg. It is not possible for me to compare these doses with other studies as I have not been able identify any studies indicating higher doses that were individually titrated for each patient. In reviewing the 68 patients I confirmed that my decision to individually titrate the dose of propranolol was based on my recognizing that my patients were responding to higher doses with a reduced level of anxiety symptoms related to past memories of traumatic events. This was documented by my patient’s experiencing: 1. a reduced need to cope by reacting to events in their lives; 2. an improvement in their ability to fall asleep of greater than 80% as their thinking slowed down when they were trying to fall asleep [this is often difficult for persons with PTSD as their brains are on guard and resist not being on guard; 3. reduced irritability around people; 4. less anxiety when around people; 5. reduced sudden memories of traumatic events; 6. reduced physical symptoms related to recalling past traumatic events [such as increased heart rate and breathing rate and muscle tension]; 7. reduced need to avoid situations that might trigger memories of the traumatic event[s]; 8. reduced feeling numb; 9. and reduced startle responses. Over time, a high percentage of my patients who responded to propranolol, reported reacting less and less to what was happening around them and feeling less anxious. This not reacting was a good indicator of the success of their response to the propranolol and their ability to make use of the support and encouragement from me. They were more aware of not responding like they used to and felt that they were more like the way they wanted to be and it felt more natural. It was at this point that I would encourage my patients to talk to themselves.

I encouraged my patients to tell themselves [out loud] that it is ok for them to not be stressed as it became clear to me that their not being as anxious could create anxiety as their brain was still believing that they needed to protect themselves by reacting to things and feeling anxious and if they were no longer doing this they could less protected and could then experience more anxiety. A few years ago, I summarized a number of studies related to someone with PTSD, when they feel calm, choosing to recall stressful events and maintaining a calm state. These studies reported that writing about these events, while remaining calm, can further help reduce the likelihood of flashbacks and intrusive thoughts, etc. and I incorporated that into my recommendations to my patients. It seems helpful for my patients who are ready to choose to recall traumatic events and not react to them with the writing part helping to convince their brains that they really do not need to react anymore. The importance of my patients reassuring their themselves that they do not need to be stressed anymore helps their brains to drop being on guard so that in the future if an event occurs that would have led to a stress reaction, it no longer does. This saves my patients the significant stress of doing well and then having an event trigger their brain and their brain responding instantly with a stress reaction like it did before. Unless their brains are told otherwise, it will react instantly to protect them. So, I encourage my patients when they are ready, to tell their themselves that it is ok not to be stressed and not to have stress reactions. It is actually better than ok since when the brain does not have to be on guard it is calmer and not wearing down the immune system by having frequent stress responses and will then be able to respond to any new event without feeling stressed. Really!

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