Psychopharmacology for Trauma-Related Disorders

Psychopharmacology for Trauma-Related Disorders - Stress Busters

• Primarily addresses Post-Traumatic Stress Disorder (PTSD); also Acute Stress Disorder (ASD) & Adjustment Disorders.
• Goals of pharmacotherapy:
  • Reduce core PTSD symptoms (intrusions, avoidance, negative alterations in cognition/mood, hyperarousal).
  • Improve daily functioning & quality of life.
  • Manage comorbid conditions (e.g., depression, anxiety, substance use).
• First-Line Treatments: Selective Serotonin Reuptake Inhibitors (SSRIs) & Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs).
  • SSRIs: Preferred initial agents.
    • Sertraline: 50-200 mg/day (FDA approved).
    • Paroxetine: 20-60 mg/day (FDA approved).
    • Fluoxetine: 20-60 mg/day.
  • SNRIs:
    • Venlafaxine XR: 75-300 mg/day. Effective for overall symptom reduction.
• Duration: Continue for 6-12 months post-remission; longer for recurrent illness.

⭐ Prazosin (alpha-1 adrenergic antagonist) is effective for nightmares and sleep disturbances in PTSD. Typical dose: Start 1 mg, titrate up to 2-15 mg at bedtime based on response and tolerability (monitor for hypotension).

Psychopharmacology for Trauma-Related Disorders - Nightmare Ninjas

• Prazosin: Alpha-1 adrenergic antagonist. Primary for PTSD nightmares.
  • Mechanism: ↓ Central noradrenergic hyperactivity during REM sleep, reducing nightmare intensity/frequency.
  • Dose: Start 1 mg HS. Titrate slowly (by 1-2 mg q few days) to 2-15 mg (max 20 mg).
  • Monitor: BP (first-dose orthostatic hypotension). First dose at bedtime.
  • 📌 Mnemonic: "Prazo-SIN stops nightmares SINister."
• Cyproheptadine: 5-HT2A antagonist, antihistaminic.
  • Alternative for nightmares. Dose: 4-12 mg HS.
• Trazodone: SARI.
  • For PTSD-related insomnia; may also reduce nightmares. Dose: 50-200 mg HS.
• Atypical Antipsychotics (Adjunctive, low dose):
  • E.g., Risperidone, Olanzapine, Quetiapine.
  • For severe, refractory nightmares or comorbid psychotic symptoms.

⭐ Prazosin is specifically recommended for PTSD-associated nightmares and sleep disruption due to its targeted action on noradrenergic hyperreactivity.

Psychopharmacology for Trauma-Related Disorders - Steer Clear & Strategize

• Steer Clear:
  • ⚠️ Benzodiazepines (BZDs): Generally avoid for PTSD.
    • Risks: Dependence, disinhibition, ↓ coping, worsens trauma processing, interferes with therapy.
    • Use: Short-term (days) ONLY for acute, severe agitation if no alternative.
• Strategize (Pharmacotherapy Pathway):
  • First-line: SSRIs (Sertraline 50-200 mg/day, Paroxetine 20-60 mg/day).
    • Start low, titrate slow. Minimum 4-6 weeks trial.
  • Second-line: SNRIs (Venlafaxine XR 75-225 mg/day). If SSRI fails/partial response.
  • Nightmares/Sleep: Prazosin (alpha-1 antagonist) 1-15 mg HS. Monitor hypotension.
  • Augmentation (Severe/Resistant): Atypical antipsychotics (e.g., Risperidone) low dose.
  • Avoid monotherapy: TCAs, MAOIs (side effects). Bupropion may worsen anxiety.

⭐ Sertraline and Paroxetine are FDA-approved first-line pharmacotherapies for PTSD.

High‑Yield Points - ⚡ Biggest Takeaways

• SSRIs (Sertraline, Paroxetine) are first-line for PTSD due to efficacy and tolerability.
• Prazosin is specifically used for nightmares and sleep disturbances in PTSD.
• Benzodiazepines are not recommended for PTSD; risk of dependence and symptom worsening.
• SNRIs (Venlafaxine) are a second-line option if SSRIs are ineffective or not tolerated.
• Atypical antipsychotics may be used as adjuncts for severe, refractory PTSD symptoms.
• Avoid monotherapy with anxiolytics for core PTSD symptoms_._