Why are psychological debriefing and benzodiazepines (BZDs), such as alprazolam (Xanax) or clonazepam (Klonopin), contraindicated in the treatment of post-traumatic stress disorder (PTSD)?

Why Psychological Debriefing and Benzodiazepines Are Contraindicated in PTSD Treatment

Both psychological debriefing and benzodiazepines are contraindicated in PTSD treatment because high-quality randomized controlled trials demonstrate they either fail to prevent PTSD or actively worsen outcomes, with debriefing increasing PTSD rates from 9% to 26% at 13 months and benzodiazepines increasing PTSD development from 23% to 63% at 6 months. 1, 2

Psychological Debriefing: Evidence of Harm

What Debriefing Involves

• Psychological debriefing is a single-session intervention administered within 24-72 hours after trauma, lasting several hours, where participants describe their thoughts, feelings, and behavioral reactions during the traumatic event in an attempt to ventilate emotions and process the trauma 1

Why It Fails and Causes Harm

Meta-analyses and systematic reviews conclusively demonstrate no benefit:

• The Rose et al. (2001) meta-analysis failed to demonstrate efficacy and concluded that "compulsory debriefing of victims of trauma should cease" 1
• Well-designed RCTs show debriefing fails to reduce post-traumatic psychopathology in crime survivors and motor vehicle accident victims 1

Two landmark RCTs demonstrate actual harm:

• Bisson et al. (1997) found that burn victims who received debriefing had significantly higher PTSD rates at 13 months compared to controls (26% vs 9%), with significantly higher scores on PTSD, anxiety, and depression measures 1
• Mayou, Ehlers, and Hobbs (2000) found motor vehicle accident survivors who received debriefing were significantly more impaired on PTSD and psychiatric symptoms at 3-year follow-up, with high-symptom individuals who were debriefed remaining highly symptomatic while non-debriefed controls improved markedly 1

The Critical Distinction

• Despite nearly everyone describing debriefing as subjectively "helpful," the objective evidence shows debriefed individuals exhibit equal or worse post-traumatic psychopathology than non-debriefed individuals 1
• This disconnect between subjective satisfaction and objective outcomes makes debriefing particularly dangerous, as it appears helpful while potentially interfering with natural recovery processes 1

Current Guideline Recommendations

• The American Psychological Association and Department of Veterans Affairs/Department of Defense guidelines explicitly recommend against psychological debriefing, stating it should not be used as randomized controlled trials do not support its usefulness and it may be harmful 3, 4

Benzodiazepines: Evidence of Harm and Inefficacy

The Striking Evidence Against Benzodiazepines

Prospective study demonstrates dramatically increased PTSD risk:

• Gelpin et al. (1996) found that 63% of trauma survivors receiving benzodiazepines (clonazepam or alprazolam) developed PTSD at 6 months compared to only 23% receiving placebo—a nearly three-fold increase in PTSD development 3, 5, 2, 6

Systematic review and meta-analysis confirms inefficacy and harm:

• A 2015 systematic review of 18 clinical trials and observational studies (5,236 participants) concluded that benzodiazepines are ineffective for PTSD treatment and prevention, with risks outweighing potential short-term benefits 2
• Benzodiazepines are associated with worse overall PTSD severity, significantly increased risk of developing PTSD when used after recent trauma, worse psychotherapy outcomes, aggression, depression, and substance use 2

Specific Problems in PTSD Populations

Benzodiazepines interfere with trauma processing:

• They may impede the natural emotional processing and memory consolidation necessary for recovery from trauma 2
• They worsen psychotherapy outcomes, potentially by preventing the emotional engagement required for effective trauma-focused treatment 2

Additional risks specific to PTSD patients:

• Increased aggression and depression 2
• Higher substance use and abuse potential in a population already at elevated risk 7, 2
• Potential depressogenic effects 7

Current Guideline Recommendations

Strong recommendations against use:

• The 2023 VA/DoD Clinical Practice Guideline strongly recommends AGAINST benzodiazepines for PTSD treatment 3, 5
• The 2010 VA/DoD guideline states benzodiazepines are not recommended in the treatment of PTSD, either as monotherapy or used adjunctively 8
• Multiple guidelines consider benzodiazepines relatively contraindicated for patients with PTSD or recent trauma 3, 2

What Should Be Done Instead

For Early Intervention (Within First Month)

Brief trauma-focused CBT starting at 2 weeks:

• Brief CBT (4-5 sessions) beginning approximately 2 weeks after trauma, combining prolonged exposure with stress inoculation training, prevents chronic PTSD development 1, 4
• Studies show only 8-20% of patients receiving brief CBT meet PTSD criteria at treatment end and 17-23% at 6-month follow-up, compared to 56-83% with supportive counseling 1, 4

Critical timing:

• Avoid any intervention in the first 24-72 hours (when debriefing is typically administered) 3, 4
• Begin trauma-focused treatment around 2 weeks post-trauma 1, 4

For Established PTSD

First-line treatment:

• Trauma-focused psychotherapies (Prolonged Exposure, Cognitive Processing Therapy, or EMDR) show 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions 3

Pharmacotherapy when indicated:

• SSRIs (sertraline or paroxetine) are first-line medications with 53-85% response rates and FDA approval 3, 5, 7
• Continue for at least 6-12 months after symptom remission due to 26-52% relapse rates with discontinuation 3, 7

Common Pitfalls to Avoid

• Do not confuse subjective patient satisfaction with objective clinical outcomes—debriefing feels helpful but worsens long-term outcomes 1
• Do not prescribe benzodiazepines for acute stress reactions or sleep disturbances in trauma survivors—they increase PTSD risk and worsen outcomes 3, 2, 6
• Do not delay trauma-focused treatment waiting for "stabilization"—evidence shows trauma-focused therapy is safe and effective even in complex presentations 3, 5
• Do not use benzodiazepines as adjuncts to psychotherapy—they worsen psychotherapy outcomes 2