The traumatic event of a burn injury can precipitate acute stress symptoms of nightmares, flashbacks, hyperarousal and disturbed sleep patterns. In some acutely burned hospitalized patients these symptoms may be significantly distressing, not respond to brief psychotherapeutic interventions, and may require pharmacotherapy. This regional burn center has seen clinically positive results with a small sample of patients using low doses of risperidone. In light of these clinical observations a preliminary retrospective pilot study was undertaken. Ten patients fit the criterion of having clinically significant distressing acute stress symptoms and were treated with risperidone. All 10 reported symptom diminishment or relief 1 to 2 days after starting risperidone. Improvement was defined as decreased sleep disturbances, diminished nightmares/flashbacks, and decreased hyperarousal. None of the patients reported any side effects from the low dose of risperidone (0.5–2 mg at bedtime; average dose was 1 mg). Patients with less clinically distressing symptoms were treated with supportive therapy and guided imagery. Results need to be interpreted cautiously because of the small sample size and lack of a control group. However, the results are encouraging enough to warrant a prospective study in order to better understand the efficacy of the use of risperidone in treating such symptoms in burn patients.