Medications to Treat Trauma, Part 2: The Use of SSRIs and Other Serotonergic Medications

While medications are not a complete solution for alleviating trauma-related suffering, they are powerful tools in treating developmental trauma and post-traumatic stress disorder (PTSD). They can reduce symptom intensity, enhancing the ability to engage in trauma-informed psychotherapy, as discussed in my previous post. [https://www.drjonslaughter.com/post/understanding-trauma-how-medications-help-with-ptsd-and-developmental-trauma]. This post builds on that discussion, offering insights into the practical use of selective serotonin reuptake inhibitors (SSRIs) and other serotonergic medications. My clinical approach prioritizes using the lowest effective dose to reduce distress and improve functioning. Let’s explore this through a clinical example.

Serotonergic medications act like a volume dial, reducing symptom intensity to improve functioning rather than eliminating symptoms entirely.”

Case Example: Anne’s Experience

Anne, a 42-year-old architect, presented at her first appointment reporting intense “anxiety,” difficulty falling asleep, and problems concentrating, which were interfering with her work. She had previously been in therapy for anxiety with limited benefit and wondered if she had attention-deficit/hyperactivity disorder (ADHD). This presentation is common, and without a trauma-informed approach, Anne could be misdiagnosed with ADHD, as research indicates many mental health practitioners do not routinely practice trauma-informed care.

After taking a comprehensive trauma history, it became clear that Anne exhibited symptoms of hyperarousal consistent with PTSD from childhood trauma. She endured repeated verbal and emotional abuse, physical threats, and occasional physical abuse from a parent, alongside bullying throughout middle school. She reported persistent emotional distress consisting of core feelings of anxiety, powerlessness, and inadequacy, particularly when interacting with her supervisor or partner during conflicts. She also described experiencing “impostor syndrome” at work.

Anne’s primary symptoms included intrusive thoughts of something bad happening, physical symptoms (racing heart, stomach discomfort), irritability, disrupted sleep, and hypervigilance, leading her to avoid distressing situations and people. Her concentration and attention difficulties began in childhood, likely due to the impact of persistent fear and hyperarousal on the development of her frontal lobes, which govern attention and impulse control. She also reported challenges with impulse control, including occasional excessive drinking, a brief period of daily alcohol use, and risky sexual behaviors in her youth. These symptoms could easily be mistaken for ADHD, but they stemmed from her trauma.

Anne frequently felt sad, lost interest in favorite activities, and experienced periods of intense, persistent depression affecting her energy, libido, and appetite. At times, she felt so hopeless that she had passive suicidal thoughts. This pattern is common in individuals with developmental or discrete traumas (e.g., assault). Prolonged hyperarousal often leads to depressive symptoms, compounding emotional distress.

As you can see from the above Jane is not just suffering with “anxiety.” Her symptoms are more complex than generalized anxiety. Anne struggled with all three symptom domains that occur in developmental trauma and PTSD: hyperarousal, cognitive difficulties, and depressive symptoms.

Medication Options for PTSD

Two primary medication classes are effective as the backbone of a regimen for PTSD: serotonergic medications and adrenaline blockers. These are typically taken daily, either alone or in combination. The decision to use medication involves weighing potential benefits against risks, including side effects and interactions with other medications. This post focuses on serotonergic medications, with adrenaline blockers to be covered in a future post.

Serotonergic Medications

Serotonergic medications reduce the intensity of PTSD symptoms across all three domains: hyperarousal, cognitive difficulties, and depressive symptoms. These include:

• SSRIs (Selective Serotonin Reuptake Inhibitors): Sertraline (Zoloft), Fluoxetine (Prozac), Escitalopram (Lexapro), Paroxetine (Paxil), etc.

• SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors): Venlafaxine (Effexor), Desvenlafaxine (Pristiq), and Duloxetine (Cymbalta)

• Other Serotonergic Medications: Mirtazapine (Remeron), Vilazodone (Viibryd).

• Tricyclics: Nortriptyline, Imipramine, etc.

What to Expect

The traditional approach historically has been to begin with an SSRI. While Sertraline, Paroxetine, and Fluoxetine have FDA approval for PTSD (a rigorous and costly process), all SSRIs can reduce symptom intensity across the three domains. Large meta-analyses indicate that Escitalopram and sertraline are the most effective and well-tolerated.

These medications act like a volume dial, reducing symptom intensity to improve functioning rather than eliminating symptoms entirely. Sustainable healing depends on non-medication interventions, such as trauma-informed psychotherapy, once symptoms are more manageable. Most individuals notice reduced hyperarousal within 2–3 weeks and tolerate SSRIs well. Depressive symptoms often improve next. If no improvement occurs after 4–6 weeks, a dose increase may be necessary. Improved concentration and attention may occur after sustained improvement of hyperarousal and depressive symptoms.

Potential Side Effects

Common initial side effects include gastrointestinal issues (nausea, changes in bowel patterns), which typically resolve within 7–10 days. Some individuals sadly discontinue SSRIs prematurely due to these side effects before benefits emerge. Ginger (tea or capsules) can help manage nausea, and persisting through the side effects is recommended. Less commonly, individuals may feel activated or sedated initially; sedation can often be managed by switching to nighttime dosing. Long-term, sexual side effects (decreased libido, delayed orgasm, inability to orgasm, or erectile dysfunction) are most common. Erectile dysfunction can often be addressed with medications like Sildenafil (Viagra) or Tadalafil (Cialis), while other sexual side effects can be managed in collaboration with a provider.

Serious but rare side effects include but are not limited to:

• Suicidal Ideation: More common in children, adolescents, and young adults, though possible across all ages. Immediate evaluation and discontinuation (in consultation with a provider) are critical if this occurs.

• Serotonin Syndrome: A typical and intended increased level of serotonin with the use of these medications improves one’s hyperarousal and depressive symptoms. However, if one experiences a flood of serotonin, it impairs the functioning of the brain and body, just as if one experienced a higher than normal level of sodium or calcium which are crucial to the functioning of the human body at normal levels. The body is meant to be in balance. Excessive serotonin can cause delirium, confusion, elevated heart rate, and high blood pressure. This requires immediate discontinuation and emergency evaluation, potentially including hospitalization.

• Hyponatremia: Dangerously low sodium levels can impair bodily functions and are detectable through routine blood work. The medication must be stopped if this occurs.

Some individuals report “emotional flattening” on SSRIs, describing feeling “not like themselves.” In my experience, this often reflects the intended effect of reduced distress. For those accustomed to chronic hyperarousal and sadness, this new state can feel unfamiliar but is not necessarily negative. Adjusting to this change takes time.

For more information on SSRIs, including risks and side effects, visit: Cleveland Clinic SSRI Information, https://my.clevelandclinic.org/health/treatments/24795-ssri .

Other Serotonergic Medication Options

If SSRIs are ineffective or poorly tolerated, other serotonergic medications may be considered. SNRIs, which affect both serotonin and norepinephrine (a neurotransmitter linked to arousal, mood, and concentration), are a common alternative. They are generally as well-tolerated as SSRIs but have a shorter half-life, requiring consistent daily dosing to avoid withdrawal symptoms.

The following serotonergic medications may also be of benefit:

• Mirtazapine (Remeron): Sedating and helpful for sleep issues but may cause weight gain.

• Vilazodone (Viibryd): May cause fewer sexual side effects.

• Tricyclics: More potent but associated with sedation, weight gain, sexual side effects, and serious cardiac risks, making them less commonly used.

Serotonergic medications reduce the intensity of PTSD symptoms across all three domains: hyperarousal, cognitive difficulties, and depressive symptoms.

Serotonin Withdrawal

Discontinuing SSRIs or other serotonergic medications should be done intentionally under your prescriber’s care, ideally after symptom improvement from psychotherapy, though it may be due to intolerable side effects. Withdrawal symptoms, such as “brain zaps” (electrical sensations in the brain), electrical sensations in the skin, increased anxiety, or irritability, can occur. To minimize these, the dose should be tapered slowly over weeks. Fluoxetine (Prozac), with a long half-life (4–6 days, with an active metabolite lasting up to 9 days), can facilitate a smoother taper by gradually reducing drug levels if one is unable to tolerate the titration of their medication.

Withdrawal prevalence is debated. Recent studies, including one by psychiatrists who experienced withdrawal themselves, suggest it is more common than previously thought. Online forums often amplify negative experiences due to selection bias, as those without withdrawal symptoms rarely share their stories. The true prevalence lies between these extremes. If withdrawal symptoms occur, contact your provider to discuss restarting the medication, slowing the taper, or switching to fluoxetine.

Anne’s Experience with Serotonergic Medication

After discussing options, Anne chose escitalopram (Lexapro) based on its evidence-based effectiveness and a family member’s positive response. Within three weeks, she experienced reduced emotional distress (notably less anxiety) and fewer physical symptoms. Soon after her mood atarted to improve, with less irritability and intrusive thoughts, and she felt less hypervigilant. Initially, she experienced sleepiness, so her doctor adjusted the dose to bedtime, which improved her sleep.

After two months, Anne’s emotional distress decreased further, though some symptoms persisted at a lower intensity. Triggers occasionally intensified her symptoms, which she addressed in trauma-focused psychotherapy. She developed sexual side effects (decreased libido and delayed orgasm) but she felt the benefits outweighed these. Her doctor suggested a “drug holiday” (skipping doses for two days before planned sexual activity), which effectively mitigated these side effects.

Over months, Anne’s concentration improved, restoring her work performance and allowing her to resume leisure reading, an activity she had feared she’d never enjoy again.

Deprescribing

Once an effective regimen is established, I recommend continuing it for at least six months. After being in distress for so long you deserve to experience greater peace and happiness for some time to allow for recovery from the prolonged suffering. There is an additional reason why it is important to not stop too quickly. Being in a reduced state of distress over time in itself can reduce the overall trend of excitatory brain signaling responsible for the state of hyperarousal as your flight-fight-freeze response is not continually being activated.

After this period, deprescribing may be considered if symptoms are well-managed. I have found the ability to do this is dependent on the degree to which one actively engages in their healing process. This of course includes active engagement in psychotherapy, and perhaps more important, what you do outside of your therapy appointments. Engaging in the practice of self-compassion on a regular basis [https://www.drjonslaughter.com/post/the-power-of-self-compassion-in-treating-ptsd-depression-and-anxiety], actively learning about the effects and impacts of trauma [https://ifs-institute.com], and regularly using mindfulness and distress tolerance skills from dialectical behavioral therapy (DBT) will foster your healing. I have created mindfulness and compassion focused meditations on my YouTube channel that you may want to visit to cultivate more healing. (www.youtube.com/@drjonslaughter)

Deprescribing should be gradual to avoid symptom recurrence. If symptoms increase after stopping, non-medication strategies can often manage them, though restarting the medication may be necessary in some cases.

Conclusion

For those struggling with trauma symptoms, I empathize with your pain. I hope this post, alongside my series on non-medication tools and medications for trauma, provides valuable insights. Explore my earlier posts on healing approaches and my new series, Let Thy Food Be Thy Medicine [insert link], for additional resources.

References

1. Stein, D. J., Ipser, J. C., & Seedat, S. (2006). Pharmacotherapy for post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, (1). DOI:10.1002/14651858.CD002795.pub2

2. Davidson, J. R. T., Rothbaum, B. O., van der Kolk, B. A., Sikes, C. R., & Farfel, G. M. (2001). Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder. American Journal of Psychiatry, 158(5), 640–645. DOI:10.1176/appi.ajp.158.5.640

3. Marshall, R. D., Beebe, K. L., Oldham, M., & Zaninelli, R. (2001). Efficacy and safety of paroxetine treatment for chronic PTSD: A fixed-dose, placebo-controlled study. American Journal of Psychiatry, 158(12), 1982–1988. DOI:10.1176/appi.ajp.158.12.1982

Disclaimer

This blog is for informational and educational purposes only and is not medical advice, diagnosis, or treatment. Information about psychiatric medications, their uses, or side effects is general and not a substitute for professional medical advice from a licensed psychiatrist or healthcare provider. Always consult a qualified healthcare professional before starting, stopping, or modifying any medication or treatment plan. Individual responses to medications vary, and only a licensed professional can assess your specific needs. The author is not responsible for any adverse effects or consequences from using this information. By reading, you acknowledge that this content is not a replacement for professional medical care and assume all risks of applying or misinterpreting it.