Psychopharmacology for Aggression and Complex Trauma
Primary Recommendation
For aggression in the context of complex trauma, initiate an SSRI (sertraline 50-200mg daily or paroxetine 20-60mg daily) as first-line pharmacotherapy while simultaneously providing trauma-focused psychotherapy without delay. 1, 2
Treatment Algorithm
Step 1: Initiate SSRI Therapy
- Start sertraline 50mg daily or paroxetine 20mg daily as these are FDA-approved for PTSD and demonstrate efficacy for both trauma symptoms and irritability/aggression 2, 3
- Sertraline shows 53-85% response rates in PTSD and has been shown to reduce anger-state and irritability within 2 weeks of treatment 1, 4
- Titrate sertraline up to 200mg daily or paroxetine up to 60mg daily based on response 2, 4
- Continue for minimum 9-12 months after symptom remission to prevent relapse (26-52% relapse rate with early discontinuation) 1, 5
Step 2: Concurrent Trauma-Focused Psychotherapy
- Do not delay trauma-focused therapy for a "stabilization phase" - this is not evidence-based and can be iatrogenic by communicating the patient cannot handle their memories 6, 1
- Initiate exposure therapy, cognitive restructuring, or EMDR immediately, which directly addresses emotion dysregulation and impulsivity that fuel aggression 1
- Trauma-focused CBT shows 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions with more durable benefits than medication alone 1, 5
Step 3: If Inadequate Response After 6-8 Weeks
Add mood stabilizer for persistent aggression:
- Valproate (divalproex) 250-500mg twice daily, titrating to therapeutic blood level of 40-90 mcg/mL 7, 8
- Carbamazepine is an alternative first-line option for agitation and aggression 8
- Propranolol 20-40mg three times daily has Grade B evidence for reducing aggression specifically 8
Step 4: Refractory Cases
Consider atypical antipsychotic augmentation only for severe, treatment-resistant aggression:
- Quetiapine 25-200mg twice daily for prominent agitation and combativeness 7
- Reserve for cases where paranoia or severe behavioral dyscontrol persists despite adequate trials of above interventions 2
Critical Pitfalls to Avoid
- Never use benzodiazepines - 63% of patients receiving benzodiazepines developed PTSD at 6 months versus 23% with placebo, and they worsen long-term PTSD outcomes 1, 2
- Avoid labeling patients as "too complex" for trauma-focused therapy - this delays effective treatment and reduces patient confidence without evidence supporting the need for prolonged stabilization 6, 1
- Do not use neuroleptics as first-line - there is no evidence of efficacy for long-term use in trauma-related aggression; reserve only for acute crisis situations 8
- Monitor for paradoxical worsening - a small percentage of patients show increased irritability on SSRIs requiring dose reduction or discontinuation 4, 9
- Beware of dose exhaustion - sertraline may require dose increases after months of treatment to maintain efficacy for anger control 4
Monitoring Strategy
- Assess aggression and trauma symptoms weekly for first month using validated scales 1
- Check valproate levels if added (target 40-90 mcg/mL) 7
- Monitor for SSRI response by week 2-4; full response may take 6-8 weeks 2, 4
- If physical aggression toward self increases on SSRI, consider dose reduction as this occurred significantly more on SSRIs in one study 9