MILITARY MEDICINE, 164, 8:605, 1999
Case Report
Risperidone as an Adjunct Therapy for
Post-Traumatic Stress Disorder
Guarantor: CPT Daniel Krashin, MC USA
Contributors: CPT Daniel Krashin, MC USA*; MAJ Elizabeth W. Oates, MC USAt
Risperidone, an atypical antipsychotic medication, has gained
wide acceptance as a first-line drug for several indications.
Recently, interest has arisen in the use of risperidone as an
adjunct therapy in post-traumatic stress disorde~ (PTSD).
PTSD is a possible sequela of exposure to traumatic events.
The military population, because of occupational exposure, is
at a higher risk than the general population to develop PTSD,
and the treatment of PTSD may be a significant issue for
military practitioners. PTSD may be complicated by social
issues and comorbid psychiatric conditions, and it is often
difficult to treat. We present two case reports on the use of
risperidone in the treatment of the intrusive thoughts and
subsequent emotional reactivity experienced by some PTSD
patients, along with a discussion of some possible mecha-
nisms of action for the efficacy of risperidone in the treatment
of these symptoms.
Introduction
ost-traumatic stress disorder(PTSD) is one possible sequela
P ofexposure to extreme trauma. Extreme trauma in the case
of PTSD is defined as trauma characterized by the threat of
death or seriousinjuryor threat to bodily integrity, such as rape
or sexual abuse. This trauma must produce severe horror or
helpless feelings in the victim. When the actual condition devel-
ops,the symptoms are distributedin three separate areas. First,
the patient "reexperiences" the trauma byrecollections, dreams,
or "flashbacks." Flashbacks are experiences in which the pa-
tient, whether awake or dreaming, feels as if he or she were
actually experiencing the trauma again. The flashbacks may
include actual perceptual distortions or even hallucinations.
Naturally, such recollections are oftendistressing, so the second
area of symptoms involves the avoidance of persons, places, or
things that maytrigger them, accompanied by emotional numb-
ing and a sense offoreshortened future. Finally, the disorderis
characterized by signs and symptoms of hypervtgilance and
hyperarousal, such as irritability, difficulty sleeping, and excess
checking and scanning, as if in expectation ofbeingattacked.1
In the overall U.S. population, the greatest number of PTSD
cases are associated with sexual assault or abuse. The military
population faces an additional vulnerability to PTSD because
military personnel are exposed to violence through wars, oper-
ations other than war, training accidents, and disaster re-
sponses. Studies have shown that although the lifetime preva-
Community Mental Health Services, Fort Riley, KS.
Department ofBehavioral Medicine, Fort Sill, OK 73503.
This manuscript wasreceived for review inJanuary 1998. The revised manuscript
was accepted for publication in October 1998.
605
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lenceofPTSD in the general population is 10/0 to 14%, it maybe
as highas 300/0 to 58°A> in populations such as combatveterans.
PTSD can be difficult to treat. Theremaybe other psychiatric
conditions present that complicate the course of the disorder.
People with preexisting personality disorders or previous expo-
sure to trauma have a greatervulnerability to developing PTSD
when they are exposed to new traumatic events. Substance
abuse or dependence, which may develop as a result of self-
medication or may have been present before the trauma and
may lead to a greater propensity to be exposed to traumatic
occurrences and less ability to process the events, also can
complicate the clinical picture and treatment of PTSD. In the
military/ government medical system, conscious or unconscious
secondary gainmayinterfere withrecovery, in that patients may
derive benefits such as assuming a sick role or receiving mon-
etary compensation for remaining ill.
Still, most patients recover or improve. However, there remain
the complicated and resistant cases, and therefore the need to
explore newtherapies. Currently, specialized treatment groups,
cognitive-behavioral interventions, treatment ofdepression and
other comorbid disorders, and symptomatic pharmacological
reliefof autonomic symptoms are popular and accepted treat-
ments of PTSD. Conventional antipsychotics agents (such as
haloperidol) are believed to be not very beneficial and are not
widely used.? However, symptoms such as flashbacks and hy-
pervigilance are similar and sometimes even identical to the
symptoms labeled hallucinations and paranoia in psychotic disor-
ders. It is possible that the newer "atypical" antipsychotics agents,
such as risperidone, withtheir more favorable sideeffect profiles,
could be useful in the treatmentofsuch symptoms in JYfSD and
could be used along with other therapies to improve outcomes
whensuch symptoms are significant in the presentation.
Risperidone may be helpful because it has a much lower
incidence of extrapyramidal side effects than conventional an-
tipsychotic medications. These side effects include akathisia,
rigidity, bradykinesia, and dystonias and can interfere with
treatment and compliance. Risperidone has been widely used
in the treatment of schizophrenia, schizoaffective disorder,
Tourette's syndrome, and Pervasive Developmental Disorder,"
and there are reports of its use in PTSD.4 We present here two
case reports ofits use as an adjunct therapy in PTSD.
Case Reports
Case 1
PatientA, a 38-year-old female, was diagnosed in June 1996
with PTSD secondary to her experiences in military training
Military Medicine, Vol. 164, August 1999
 606 Risperidone for Post-Traumatic Stress Disorder

accidents and childhood abuse. She had been treated with ventral striatum, rather than on the core of this structure,
group therapy in a specialized PTSD group. Pharmacologically, compared with conventional antipsychotic medications." The
she had been treated with trazodone, venlafaxine, valproic acid, shell or outer area of this region is considered to have more
and zolpidem tartrate forher symptomsofinsomnia,irritability, "limbic system" involvement than the core, and limbic struc-
and dysthymia. She had also complained of flashbacks, hype- tures are implicated in the diseaseprocessofPTSD, especially in
ralertness, and hypervlgilance, which seemed to approach de- the emotional responses and hyperarousal. Risperidone has
lusional intensity at times. She was started on risperidone 0.5 also been reported to have nonspecific antidepressant and an-
mg twice a day in November 1996 and graduallyincreased to 3 xiolytic effects, which may address these symptoms in PTSD
mg twice a day. As her dose increased, she experienced greater patients.7,8
and greater relieffrom flashbacks and intrusive thoughts. She Finally, whether one refers to certain symptoms as "hyper-
describes risperidone as the onlymedication that she feels has vigilance," "intrusive thoughts," and "flashbacks," or as "para-
reallyhelped her. noia," "delusions," and "hallucinations," the symptoms them-
selves share many common characteristics. Despite their
Case 2 putative different origins, it is possible that similar symptoms
Patient B, a 33-year-old male, was diagnosed with PTSD in may share some common neurological pathways. Medications
January 1995 secondary to his combat experiences in the Per- such as risperidone have provided relieffor such symptoms in
sian Gulf War and significant childhood abuse. His intrusive other disorders, and it is possible that with its more tolerable
thoughts and autonomic reactions around his traumatic expe- side effect profile it may provide reliefin PTSD as well.
rienceshad led to such violentactingout that he was orderedby In conclusion, risperidone may have a role as adjunct treat-
the court to stay awayfrom his wife and children. Hewas treated ment in PTSD when used to address symptoms such as hyper-
with group therapy in a specialized PTSD group, as well as vigilance and flashbacks, as well as by havinghelpful anxiolytic
pharmacologically at various times with lithium carbonate, or antidepressant effects. Forthe military or government mental
clonidine, fluoxetine, and zolpidem tartrate. He continued to health care practitioner who may see a substantial number of
experience intrusivethoughts ofthe trauma despitethese treat- patients withthis disorder, risperidone maybe a usefuladdition
ments and found this to be a problem, because he tended to to the pharmacological treatment of PTSD.
engage in violent acting out during these symptoms. He was
begun on risperidone 1 mg twice a day in September 1996 and
then decided to take the medication on an as-neededbasis when References
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