About Medications For Combat PTSDJonathan Shay, M.D., Ph.D.
Psychiatrist, Boston VA Outpatient Clinic
This was prepared as educational material for combat veterans,
but may be useful to others, such as veterans' spouses and non-physician mental
health professionals. It is in the public domain and may be duplicated and
- Point of view
- A brief course in
- Therapeutic effects
(benefits) and side-effects
- Tolerance and
- Things that help
- Characteristics of good drugs for
- Makes something better for
- Does not lead to
- Does not lead to
- Cannot be used to commit
- Does not require blood
- Does not cut a person off from the
world or from himself
- Causes few, bearable
- Some good drugs for combat
- Serotonin reuptake
inhibitors: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil),
- Buspirone (Buspar)
- Beta-blockers: propranolol
(Inderal), nadolol (Corgard), atenolol (Tenormin), etc.
- Low-dose lithium
- Other drugs for special
- Trazodone (Desyrel) for
- Quinine for nocturnal
- Low-dose antipsychotics for
violent urges: thioridazine (Mellaril), mesoridazine (Serentil), etc.
- Future drugs
- Things to avoid
- Benzodiazepines: diazepam
(Valium), alprazolam (Xanax), lorazepam (Ativan), etc.
- Any illegal drug
- Things to read
- Point of view
Everything I say here is my point of view, and carries no claim of special
authority. Also, what I say here is no way complete. I have left out many
important subjects, such as drug interactions, what medical conditions forbid
the use of a given drug, overdoses and toxicity, and most specific side-effects.
Also, many psychiatrists who also care about combat veterans will disagree with
what I say here, particularly about the benzodiazepines like Ativan.Combat PTSD
is moral, social, philosophical, and spiritual injury. The biological nature of
human beings is to be moral, social, philosophical, and spiritual, so the injury
also shows itself as medical disorders.
Healing is psychological, social, spiritual -- no medicine can cure combat
PTSD. However, healing can never mean a return to 17-year old innocence. Healing
means building a good human life with others -- a life that a veteran can
embrace as his own.
Combat trauma brings about long-lasting changes in brain chemistry. We do not
know whether these are permanent or can be reversed by psychological/social
healing. A few existing medications can help some men with some symptoms of
PTSD. We also do not know whether this changes the long-term outcome for the
better, but the human payoff in reduced suffering is unmistakable.
- A brief course in pharmacology
- Therapeutic effects (benefits) and
Drugs are dumb chemicals -- they don't know what they are. They aren't born
in a laboratory with a word spelled out across their foreheads
"Anti-depressant!" or something like that. Most have been discovered by
accident. Almost every drug known has multiple effects on the body. Which effect
is a therapeutic (beneficial or main) effect and which is an unwanted
side-effect is a human decision, not a chemical decision.
Illustrations: Think of the well-known drug Elavil (generic name:
amitriptylene). What is it? An anti-depressant you say? Why is it used in the
Intensive Care Unit to stabilize the heart beat of certain patients? Not because
depression causes their irregular heart beat. Why is it used by neurologists to
treat migraine? Not because depression causes migraine -- and the doses that
work for migraine are usually too small to touch a depression. The point is, of
course that a drug doesn't know what it is. Its successful human uses make it an
anti-depressant, a migraine drug, an anti-arrhythmic.
What about side-effects? Again, this is a matter of the human purposes
involved. Think of the anti-depressant trazodone (most common trade name:
Desyrel). Its most prominent side-effect is drowsiness. I prescribe trazodone
fairly often as a sleep medication to veterans who are on fluoxetine. It has the
advantage that it doesn't lose its effect with repeated use (which also means
there's little withdrawal syndrome when the veteran stops it), and it's almost
useless as a pill to kill yourself with. So here the side-effect is the main
effect and the anti-depressant effect is a side-effect. -- Is anybody confused
Important to remember: When a drug has several different effects, each effect
has its own way of unfolding in time. How long a drug takes to produce its
different effects, is often different for each effect. The side-effects may hit
immediately and the main effect only develop after several weeks! With another
drug it's the opposite, with the main effect coming on immediately and the side
effects happening later. An analogy: Think of a plant on your window sill.
You've been away for the weekend and its gotten dry and droopy. You give it
water and the leaves begin to respond almost as soon as the water goes on -- the
plant responds as soon as the water reaches the roots. If the roots dry out,
again the plant wilts again. This is like a pharmacokinetic effect. If you put
some fertilizer in the water, on the other hand, this reaches the roots as fast
as the water reaches them, but you may not see any result for days or weeks.
This is because the plant has to build new parts in its own cells. This is like
a pharmaco-dynamic effect.
Example: Most anti-depressants reach the brain quickly, but take several
weeks to have an anti-depressant effect. This is probably because the changes
that have to take place in the cells take that long to happen. However, some
side-effects like a dry mouth or drowsiness happen quickly because they do not
require cells to make anything new, but only to do what they're already doing
faster or slower.
- Tolerance and withdrawal
I will use alcohol as the example, because most people have considerable
knowledge about it. They just haven't realized that they can transfer this
knowledge to other drugs. Pharmacologic tolerance is a critically important
Consider a very heavy drinker, who drinks every day and more or less all day.
Most of the time he is not drunk, in the sense of staggering or slurring or not
thinking clearly. He may function quite well at his job with a blood alcohol
level that would put a non-drinker almost in a coma. This is because the drinker
has developed a tolerance to alcohol. His brain has adjusted to alcohol's
presence and slowly adapted its machinery to get everything back to normal. This
adjustment is called pharmacologic tolerance, and it takes a while to
happen. The brain has developed a steady, compensating excitation to balance the
steady sedating effect of chronic alcohol. When the two are exactly in balance,
the drinker thinks and behaves more-or-less normally. If the alcohol is suddenly
removed, the brain becomes dangerously over-excited, resulting in delirium
tremens, DTs. The compensating excitation corrects itself much more slowly than
the alcohol leaves the body. This whole set of events is called a withdrawal
The same kind of DT-like withdrawal syndrome of dangerous over-excitement
(seizures, hallucinations, etc.) happens after sudden withdrawal from high doses
of other sedating drugs that people get tolerant to, such as barbiturates,
benzodiazepines (such as Valium), etc. A good rule of thumb is that a patient
who has become tolerant to a given drug effect will get a withdrawal syndrome if
he or she stops it suddenly. Often, the withdrawal syndrome is the "mirror
image" of the original effects of the drug.
Not all of the effects of a drug are detectable by the person taking it, so
tolerance to these changes may not be subjectively felt, either. However, during
cold-turkey withdrawal from the drug, a withdrawal syndrome may develop that is
the mirror image of effects that the person was never aware of. An example of
this is caffeine withdrawal headaches. Most people are unaware of the
blood-vessel-narrowing effect of caffeine, but once tolerant to this effect,
abrupt discontinuation of caffeine can cause headaches due to blood-vessel
The greatest tolerance and the most severe withdrawal reactions happen with
long-term use. However, with some drugs, there can be a miniature version of the
whole picture with a single dose. Again, alcohol gives a good example: A man who
knocks many drinks back one after another and then stops is much more drunk when
his blood alcohol level passes a given point on the way up, than later when his
blood alcohol level passes the same point on the way down. This is called acute
tolerance, because his body has already adjusted to the presence of the alcohol
in the few hours since he started drinking. The next morning, during the
hangover, he has a mini-withdrawal syndrome making his nervous system overly
sensitive -- how loud every sound seems! -- is the mirror image of how much
alcohol deadened sound when he was drunk.
An analogy: You are running a motor boat on a certain compass heading, say
due north, on a windless day (no alcohol). Now a cross-wind begins to pick up
(gradually increasing steady drinking) and you gradually adjust the rudder to
keep on the same heading. Now you are still heading due north, despite the heavy
cross-wind. Suppose the wind suddenly dies (suddenly stopping drinking,
cold-turkey) and you keep the rudder where it was -- you start going in circles
How much tolerance develops to each drug effect varies a lot from effect to
effect and from person to person. A person may develop rapid tolerance to a
nasty side-effect, such as dizziness. This means the dizziness actually goes
away, not that the patient just gets used to it. So this person can bear with
the drug and wait around for the therapeutic effect to kick in. Another person
may never get tolerant to the dizziness side-effect and cannot make use of that
particular drug. There's no iron-clad way to predict a given person's
sensitivity to each of the effects of a given drug or how fast, if at all, he
will become tolerant to each effect.
- Things that help
- Characteristics of good drugs for combat PTSD
- Makes something better for the veteran
- Does not lead to tolerance
- Does not lead to abuse
- Cannot be used to commit suicide
- Does not require blood tests
- Does not cut a person off from the world or from
- Causes few, bearable side-effects
- Some good drugs for combat PTSD
Serotonin reuptake inhibitors: fluoxetine
(Prozac), sertraline (Zoloft), paroxetine (Paxil), etc.
The main effect of fluoxetine on combat vets with PTSD whom I've worked with
is to allow them more time to think before they act, particularly in anger. It
does this without sedation or cutting a man off from himself or the world. The
duration of anger, once aroused, is also shorter. Greater self-mastery of anger
leads to an increase in self-respect and relief from a sense of humiliation.
Most men feel humiliated after they go off on people in situations they really
would not have, if they had had the freedom to choose. In addition to this,
fluoxetine may have a direct anti-depressant effect in combat PTSD. Fluoxetine
effects on self-control and rage may take many weeks to kick in, although I've
seen it as soon as a week.
Fluoxetine is practically useless as a drug to overdose on, if the goal is
suicide. All anti-depressants have been known to give long-time depressed people
the energy to kill themselves, and fluoxetine is no different. Many combat
veterans go through brief periods of intense despair during the first few months
that they are feeling generally better, more alive, and are coming out of their
bunkers. Support from other veterans, family, therapists is especially important
during those times -- nobody should try to go through it alone, or have to.
Someone trying to go through it alone, might try to kill himself during one of
these times of despair. Remember that this is no special risk with fluoxetine,
but is a risk when anyone recovers from severe depression. Several vets I've
treated have had bouts of despair like this, but none has ever tried to kill
himself during one, because support and therapy are built into the program I'm a
part of. The much publicized claim that Prozac has special powers make a
previously non-suicidal person violently suicidal is without good foundation.
Fluoxetine does have side effects, which not everyone can stand, and it doesn't
work for everyone. A full discussion of side-effects, some of which depend on
the dose and others not, would be too long for this summary.
Fluoxetine is the first drug of its type to be released for use. Other drugs
in the same family have now come along, sertraline (Zoloft) and paroxetine
(Paxil). They have been tried by many combat vets around the country, and from
what I hear they are not a lot different than fluoxetine as far as main and
side-effects. In the relatively limited number of men I have treated with
paroxetine and sertraline, this has been what I have heard from them. Paroxetine
has a 24 hour half-life and no active metabolites [what the body turns the
parent drug into], so if the actions of the drug are otherwise identical to
fluoxetine, it will be a superior drug from a safety point of view, because it
doesn't hang around in the body so long. But on the down side, paroxetine may be
expected to (and is reported to) have a withdrawal syndrome because it leaves
the body so fast.
This anti-anxiety drug works differently from the benzodiazepines (like
Valium). Like anti-depressants it takes a few weeks to kick in. It takes effect
gradually, like the tide coming in. It usually has few side-effects and may help
some people with intrusive thoughts and nightmares. Buspirone has no street
value and is almost useless as a suicide pill. I am not aware of other drugs in
this family coming along, but I hope there will be. I have recently read the
report of a colleague who works with combat veterans that the best results with
buspirone come at doses above 60mg/day. I do not yet have enough personal
experience with patients who have tried this, to confirm or deny this report.
Beta-blockers: propranolol (Inderal), nadolol
(Corgard), atenolol (Tenormin), etc.
This family of drugs breaks the mind-body-mind vicious cycle in rage
reactions, by blocking the body effects of adrenalin. For example, if someone at
work says something offensive about Vietnam vets, the words start the mind
working into rage. The rage starts in the mind -- but within a second the body
responds with adrenalin, which makes the gut burn, the heart pound, the muscles
tense. These body changes send loud messages back up to the mind. For some
veterans, the roar of the body drowns out all thought and shuts out everything
else coming in. When adrenalin is roaring, it's impossible for most people to
think clearly and to take in non-combat possibilities in the situation. This is
the mind-body-mind vicious cycle that beta-blockers break up. By blocking the
adrenalin effect on the body they prevent the roar of the body from drowning out
all thought and choice about what you really want. "Is it really in my interests
to rip this guy's lungs out? Is it really what I want to do?" When adrenalin is
roaring these questions sometimes cannot be heard.
Some vets feel that these medications weaken them, because they associate
being pumped up with adrenalin with their personal strength. When someone is
over-medicated on these drugs (which started life as blood pressure meds) he is
weaker because his blood pressure is too unstable, but this is usually not a
problem with a correct dose.Tolerance does not develop to the anti-adrenalin
effects of these drugs. Massive overdoses of a beta-blocker can be fatal, by
dropping the blood pressure and slowing the heart to the point that the brain is
not getting enough blood flow.
Some respected practitioners of PTSD pharmacotherapy speak highly of lithium
to help veterans maintain their self-control when they are angry. This means
doses of about 600mg/day, far less than is usually need to treat bipolar
affective disorder (manic-depressive disorder), and does not imply that the
doctor recommending this thinks that the veteran is manic-depressive.
I agree that this can help some veterans, but I have found fluoxetine to be more
reliable. It is also safer, in that lithium is readily fatal in a large
overdose. For a veteran who cannot tolerate fluoxetine and whose life has been
blighted by explosive violence, low-dose lithium may be a good thing to try. [no
blood tests because of low dose]
Other drugs for special circumstances
Trazodone (Desyrel) for sleep
Trazodone is a non-toxic anti-depressant that has a useful side-effect: It
causes drowsiness, and people don't get tolerant to this effect. Because
fluoxetine slows the rate that the liver breaks down trazodone, much lower doses
are needed for sleep by patients on fluoxetine than people who are not on
Quinine for nocturnal myoclonus
This is the "sleep jerks." If quinine works, the veteran himself may not
notice much but his wife has much better sleep.
Low-dose antipsychotics for violent urges: thioridazine
(Mellaril), mesoridazine (Serentil), etc.
The key here is brief treatment on an as-needed basis, controlled by the
veteran himself. [for a limited time, when hospitalization is not possible] The
doses needed have been low, and I prefer the sedating anti-psychotics like
thioridizine and mesoridizine, which appear to carry the least risk of dangerous
(neuroleptic malignant syndrome) or possibly irreversible (tardive dyskinesia)
complications. An unexpected additional use for these drugs also involves brief,
low-dose treatment: to help someone who wants to get off marijuana get through
the withdrawal syndrome.
Many combat veterans with PTSD feel dead inside. It is possible that this
psychic numbing comes from the brain making its own opium-like substances, and
that opiate blockers can give people back their feelings. It is not yet clear
whether this works.
I hope the future will bring a drug like clonidine (trade name: Catapres)
that people do not develop a tolerance to. In my experience, about one out of
five combat veterans with PTSD experience major improvement of almost all of
their PTSD symptoms on clonidine -- but the heartbreak has been that they grew
tolerant to it in about a week. Any future drug in this family that does not
induce tolerance to this effect will relieve much suffering. A new drug in this
family, guanfacine (tradename, Tenex) has recently appeared, but I have no
experience with it and have not heard any reports of usefulness to combat
veterans with PTSD.
The most helpful drugs are likely to be ones that don't yet exist.
- Things to avoid
One of the useful things I do for veterans I see is help them identify and
get off of drugs that they use (whether prescribed by doctors of not) that are
harming them. Some of what I say here is likely to be controversial.
Things to read
- Benzodiazepines: diazepam (Valium), alprazolam
(Xanax), lorazepam (Ativan), etc.
Disinhibition: All the drugs in this class are similar to alcohol. Some
people who "lose all their inhibitions" on either alcohol or benzos or both.
This "dis-inhibition" can affect practically anything that a person thinks he
might like to do -- but doesn't do -- when sober. It has included suicide and
murder, but most often involves saying things that cumulatively do great damage
to a veteran's life. A lot of family stress among veterans comes from things
said to wives and children the veteran wishes he hadn't said, the moment it was
out of his mouth. One of the inhibitions that benzos weakens is the inhibition
about saying hurtful things to people we love. Memory loss: All of the benzos
weaken the ability to remember what happened a short time ago, including things
you yourself did or said. The more potent the benzo, the more it wipes out
short-term memory -- this is probably why Halcion (generic name: triazolam) has
been such a bad actor, it's one of the most potent. Here's a little scene that
everyone has experienced one way or another:
"I'm going out for cigarettes -- want anything?""Quart of orange juice and a
box of Pampers.""OK" Half hour later you're back -- with your cigarettes! No one
is 100% on things like this, but people on benzos are sometimes close to zero.
Short-term memory is something that everyone needs to make relationships
work, at home, at work, or anywhere. There's the additional stress that combat
vets have when they find themselves forgetting -- they have been in real
situations where people died because someone forgot. The tension and guilt that
this creates in everyday life can be unbearable, and veterans often do not know
that their benzodiazepines are responsible for memory lapses.
Confusion of pleasant side-effects with main effect: The pleasant,
couple-of-drinks, or drowsy feeling that you get when you first take a benzo
(especially the ones that are rapidly absorbed into the blood) is a side-effect
that most (not all) people get tolerant to. Because it comes on at the same time
as the anti-anxiety effect, it is natural for patients to think that this
pleasant feeling is the anti-anxiety effect. One of the strengths of the benzos
is that people do not get tolerant to the therapeutic anti-anxiety effect. A
very common problem is that people feel the drug is quitting on them when they
become tolerant to the pleasant side-effect, and become very afraid that their
anxiety symptoms will return. Often out of fear of fear, they double up on their
meds and pressure their doctors to increase their dose. This natural confusion
of a gradually weakening, pleasant side-effect with the main effect is
responsible for some addictive properties of the benzos.
Mini-withdrawal syndrome between doses: Benzos differ from each other mainly
in their pharmacokinetics, that is, how fast they go into the body and how fast
they leave. Mini-withdrawal reactions are particularly likely to happen with the
benzos that leave the body quickly, such as Halcyon (generic name: triazolam).
This is why people who take this drug for sleep often wake up in the middle of
the night because they are in the withdrawal phase. Though Xanax does not leave
the body quite as fast as Halcyon, it is particularly prone to giving
mini-withdrawals between doses. My observation has been that many combat vets on
Xanax have periods of anxiety and irritability during each day that do them
great harm, and which, in my view are mostly mini-withdrawal reactions between
Possible dangerous peculiarities of Xanax in PTSD during withdrawal: The
staff of the in-patient PTSD unit at the American Lake VA in Washington State
have published a paper reporting extreme violence by combat vets treated for
long periods with Xanax and then taken off of it. This was apparently more
frequent and more severe than what they found taking their patients off of other
benzos, such as Valium. Several Vietnam combat veteran peer counselors whom I
respect very highly, feel that Xanax has done a lot of harm. Xanax has some
unique properties among its cousins in the benzodiazepine family. In lab tests
Xanax acts the opposite at low blood levels of how it acts in the larger amounts
actually used in medical practice. When you think about it, everybody passes
through a low blood level twice when they take a pill -- once when the pill is
just being absorbed in the body and once when the body is almost done getting
rid of it (unless, of course, the person takes the same pill again, before the
first one is completely gone). Whether this is what causes the problems with
Xanax is not clear right now.
The pharmacology of caffeine is horribly complicated: it's not just one drug,
it's really three, each of which can have a different effect on different
people. The way it's three drugs is that it's the original caffeine, then the
body converts it into theobromin, which the body then converts into theophyllin.
The peak effects of these three successive drugs are roughly two hours for
caffeine, four hours for theobromin and six hours for theophyllin. The good
effects that any of these three drugs can have is feeling more awake, energetic,
and optimistic. The bad psychological effects that any of these three drugs can
have are anxiety and depression. A given person does not necessarily react to
all three the same way. (I'm not talking here about the well-known effects of
caffeine on sleep -- this is another important topic in itself. What many people
are unaware of is that at very high doses -- like 15+ cups of coffee a day --
caffeine can reverse on you and it can be impossible to stay awake, unless the
caffeine is stopped.)
Someone who reacts badly to caffeine itself has usually found that out long
ago, because the anxiety and/or depression hits them soon after the big mug of
coffee. These people know it's not for them. But there are literally millions of
people who feel good after caffeine itself but have bad reactions to either
theobromin or theophyllin (four or six hours after that big mug of coffee) and
just think it's their life that's out of whack, not their brain chemistry THERE
IS NO WAY TO TELL WHETHER CAFFEINE AND ITS METABOLITES ARE RESPONSIBLE FOR YOUR
ANXIETY AND/OR DEPRESSION UNLESS YOU TAKE YOURSELF OFF IT COMPLETELY FOR SEVERAL
WEEKS. This means coffee, tea, Coke, Pepsi, Mountain Dew, Jolt, headache pills
with caffeine. Some people are so sensitive to it that even the small amount of
caffeine in decaffeinated coffee and in chocolate causes psychiatric symptoms.
If you decide to take yourself off caffeine to see what your life is like, don't
go cold turkey. Taper yourself off over a week or so, or you are likely to get
severe withdrawal headaches.
Yohimbine (brand names: Actibine, Aphrodyne, Yocon, Yohimex) is absolutely
contraindicated in combat PTSD. It causes flashbacks and panic attacks. This
drug is sometimes used to treat impotence.
Any illegal drug
The problems and appeals of specific illegal drugs in combat PTSD is a very
big subject that can't be covered here, but all illegal drugs cause the
following problems for combat vets with PTSD.Expense is the first problem -- I
know there are Vietnam vets who have been very successful financially, but the
men I know who have severe, chronic PTSD have a heroic struggle to make ends
meet. I know it's stating the obvious, but the first problems of illegal drugs
is the expense.
The second problem is much more subtle -- Getting illegal drugs involves you
in relationships with and obligations to people you normally wouldn't let within
a mile. Most of the combat vets I know have a very sharp eye for quality in
human beings, and feel constantly tainted by the people they get involved with
to support their habits. The third problem is that situations of real danger and
the presence of weapons gets in the way of healing from PTSD. In this country
and time it's not possible to sustain a drug habit over a period of years
without running into situations that rekindle PTSD because of their real combat
The fourth problem is the worst -- using illegal drugs often puts veterans in
situations where they bring down other vets. Calling for rescue is a very common
way of bringing down other vets, even if the rescue is "successful." Users need
to be rescued from the medical complications of their habits, from the pressure
of debts to dealers, and so on. Vets who have been on rescue missions are put
back into combat-mode and are wired for weeks after a rescue. Sometimes users
bring down other vets by asking them for dangerous favors (e.g., "hold this for
me till I come for it" where "this" is a parcel of drugs or drug-related weapons
or money). And finally -- this is really obvious but it needs to be said -- if a
fellow vet is trying to stay clean and you're using, this amounts to a standing
invitation to break out.
|If you like my "voice" and might be interested in reading more on combat
PTSD, I have written Achilles in Vietnam: Combat Trauma and the Undoing of
Character, published by Simon & Schuster Touchstone paperbacks. An
assortment of veterans' and others' comments, published and unpublished, on the
book can be found at the Post Exchange, part
of the Vietnam Veterans Home
Page, and at amazon.com.
|The Post-Traumatic Gazette is a
bi-monthly newsletter of consistently high quality, and subscriptions are within
the reach of suffering family members who do not have easy access to the
Internet. Other Patience Press books and pamphlets are similarly reasonable and
non-exploitative in their price.
I know Patience Mason quite well and think *very* highly of her
spouse/children/family/workplace education efforts on combat PTSD. She is a
respected member of the International
Society for Traumatic Stress Studies and has truly useful teachings to
(I have no financial connection with her or her press, and I receive no
freebies, paying for my own subscription to her Gazette.)