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Resident in Pediatrics, Psychiatry, Child & Adolescent Psychiatry, Departments of Pediatrics, Child & Adolescent Psychiatry, Utah Health Sciences Center, 650 Komas, Suite 208, Salt Lake City, Utah 84108, fax 801/585-9096, brooks.keeshin{at}hsc.utah.edu
Clinical Fellow in Child & Adolescent Psychiatry, Division of Psychiatry, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
Published Online, July 7, 2009. www.theannals.com, DOI 10.1345/aph.1M219
Case Report. A 13-year-old boy experienced chronic PTSD (DSM-IV TR criteria) related to sexual abuse and neglect. Since the age of 8 years, he required 8 hospitalizations for aggression and self-harm, predominately triggered by flashbacks, oppositionality, and conflict with his mother. He had been maintained on a regimen of divalproex (24 mg/kg divided twice daily, serum concentration 112 mg/dL) and clonidine 0.15 mg orally at bedtime. Initially, his clinical presentation was characterized by hypervigilance, irritability, and oppositionality. In addition, he presented a constellation of intrusive symptoms including frequent flashbacks of the sexual abuse and witnessed violence, occasional nightmares, initial insomnia, frequent feelings of detachment, blunted affect, intermittent mood-congruent trauma-related auditory hallucinations, and paranoia.
Risperidone (0.5 mg orally twice daily) was added to his regimen and within 2 days, the patient noted decreased intrusive symptoms and decreased flashback frequency. Moreover, he denied nightmares and experienced normal sleep latency. The staff reported that the patient was less hypervigilant. To target residual hallucinations and paranoia, the risperidone dose was increased to 0.5 mg orally each morning and 1 mg orally at bedtime on day 4. At that time, the patient noted mild unilateral breast tenderness but denied galactorrhea. Physical examination revealed no gynecomastia or evidence of breast mass; however, his serum prolactin level was 44 ng/mL (normal range for males: 2-17 ng/mL). The risperidone dose was decreased to 0.5 mg orally twice daily; clonidine and divalproex were continued as previously prescribed and the breast tenderness resolved over 2 days. On this regimen, the patient continued to do well, without a subsequent hospitalization for 10 months in follow-up. Moreover, he and his guardian continued to report minimal PTSD symptoms.
Discussion. This case extends the findings of previous studies of
risperidone in the treatment of adults with PTSD to youth with PTSD. Moreover,
efficacy was observed in intrusive and hyperarousal symptoms that have been
linked to noradrenergic hyperactivation in adults with
PTSD.3 It is
of particular interest that double-blind, placebo-controlled trials of
centrally acting 
1-adrenergic antagonists such as
prazosin have shown effectiveness in reducing symptoms of PTSD in
adults4 and
that risperidone is also a potent 1-adrenergic
receptor antagonist in addition to an antagonist at D2 and
5-HT2a
receptors.5
It remains to be determined whether the efficacy of risperidone in reducing
intrusive and hyperarousal symptoms in patients with PTSD relates to its
unique combination of 1 antagonism and
D2/5-H2a antagonism or to some other
intrinsic pharmacologic properties of risperidone. Studies examining the
effects of this compound in children and adolescents with PTSD are
necessary.
Footnotes
References
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