Risperidone in PTSD

To the Editor: Chronic posttraumatic stress disorder (PTSD) secondary to combat trauma is a disabling condition often accompanied by vivid flashbacks and nightmares that make participation in therapy difficult. Because these flashbacks seem almost hallucinatory in nature, we considered using risperidone in some especially refractory cases. We chose risperidone for its favorable side-effect profile in low doses.

Although other clinicians have used antipsychotic medications to treat PTSD (1,2), we have seen no references to the use of risperidone. We present four cases in which patients with chronic, disabling PTSD who had vivid flashbacks and nightmares were treated successfully with risperidone.

Case 1. A 47-year-old married Caucasian male with PTSD and major depression was experiencing severe family stress. He was treated with 250 mg of valproate three times a day and 1 mg of clonazepam at bedtime. His flashbacks stopped after the addition of 1 mg of risperidone twice a day. On discharge, he was able to engage in family therapy.

Case 2. A 43-year-old married Latino male was in partial sustained remission from major depression, PTSD, and alcohol dependence. He was treated with 20 mg of fluoxetine every morning and 1 mg of clonazepam every six hours as needed for anxiety. After 1 mg of risperidone was added at bedtime, his nightmares decreased considerably. After discharge he participated in anger management therapy, art therapy, and a PTSD group.

Case 3. A 45-year-old single Caucasian male with PTSD, alcohol dependence, and personality disorder not otherwise specified was treated with 20 mg of paroxetine every morning, .5 mg of clonazepam three times a day, valproate in doses of 500 mg every morning and 1000 mg every evening, and 100 mg of trazodone at bedtime. After risperidone was titrated to 1 mg every morning and 2 mg at bedtime, the patient noted a significant decrease in both nightmares and flashbacks. On discharge, he discontinued all medications against medical advice, and his symptoms returned.

Case 4. A 46-year-old single Caucasian male with PTSD and major depression was being treated with 500 mg of valproate every morning and 750 mg at bedtime as well as 20 mg of paroxetine every morning. The patient's flashbacks and nightmares decreased dramatically after risperidone was titrated to 1 mg each morning and 2 mg at bedtime. However, he developed akathisia, which was successfully treated. After discharge, he functioned as the head cook in a clean-and-sober-living program and tolerated several deaths in his family without decompensation.

These cases indicate that risperidone is a viable and effective treatment for the vivid flashbacks and nightmares often found in patients with PTSD. Better control of these symptoms allows for more effective treatment of the disorder. Many questions remain to be answered, but the potential of risperidone in the treatment for this chronic and highly debilitating disorder deserves careful study.