Trauma- and Stressor-Related Disorders

Only sertraline and paroxetine carry an FDA indication for PTSD. Whether that regulatory fact tracks real pharmacologic superiority, or simply which manufacturers ran the required trials, is a genuinely separate question.

A large VA-sponsored trial found prazosin no better than placebo for PTSD nightmares, reversing years of smaller positive studies. The drug remains in widespread use anyway.

VA/DoD guidelines advise strongly against benzodiazepines in PTSD, citing worse outcomes and interference with fear extinction. Two patients, at opposite ends of the same drug, show why the guideline and the exam room keep disagreeing.

Promising trial data was not enough: the FDA declined to approve MDMA-assisted therapy for PTSD in 2024 over concerns about blinding and study conduct. A patient who has read about the treatment wants to know what that rejection actually means for her.

VA/DoD and ISTSS guidelines favor trauma-focused psychotherapy over medication as first-line treatment for PTSD. Two patients, one with a trained therapist available and one without, show why prescribing so often runs the other way anyway.

Giving propranolol in the hours after a traumatic event, before PTSD has had a chance to develop, raises a genuine clinical and ethical question: is blunting memory consolidation prevention, or is it interfering with a normal response before anyone knows it will become a disorder at all.

Trial evidence in septic shock survivors links stress-dose hydrocortisone to fewer later PTSD symptoms, not just to hemodynamics. That finding is real but genuinely underused, since almost nobody prescribes a critical-care drug with a psychiatric endpoint in mind.

A large VA trial found risperidone augmentation no better than placebo for PTSD symptoms not controlled by an SSRI alone. Real-world augmentation with second-generation antipsychotics continues anyway, often for reasons the original trial was never designed to test.

Single-dose IV ketamine produced rapid, if transient, PTSD symptom reduction in a placebo-controlled trial. Whether that justifies off-label use in a patient whose most disabling symptoms are dissociative is a genuinely separate question from whether ketamine works.

A patient beginning prolonged exposure therapy wants to also start an SSRI, assuming combining treatments can only help. Whether the added burden of two treatments at once is actually worth it — and whether an SSRI might blunt the very fear-extinction learning exposure therapy depends on — is genuinely unsettled.

Prolonged grief disorder became an official DSM-5-TR diagnosis in 2022, and grief-focused psychotherapy is its established treatment. Whether medication has any legitimate role at all in a condition built to be treated by therapy is a genuinely open question.

Adjustment disorder is, by definition, a time-limited reaction to an identifiable stressor. A patient in real distress after losing his job raises the classic tension between treating genuine suffering and medicalizing a response most people would call normal.

Blast-related traumatic brain injury and PTSD are frequently comorbid in combat veterans, and a TBI-lowered seizure threshold quietly rules out one antidepressant class entirely before the pharmacologic conversation even reaches which drug helps most.

The older model treated substance use disorder first and PTSD later. Current evidence favors integrated, concurrent treatment of both — but the pharmacologic evidence for the most commonly used PTSD-specific agent in this exact comorbidity is itself disappointing.

With prazosin's evidence base weakened by a large negative trial, mirtazapine offers a genuinely different mechanism for trauma-related nightmares — built on a smaller evidence base of its own, and carrying a side-effect profile that cuts both ways for this patient.

The VA officially cautions against cannabis for PTSD, citing thin and largely negative trial evidence. Widespread real-world veteran use continues anyway, and a patient already self-medicating forces the honest question of what to do with that gap.