MDMA & PTSD: A Comprehensive Review
For several mental health disorders, including posttraumatic stress disorders (PTSD), there are not many available treatment options. Recently, there has been renewed interest in the potential of methylenedioxymethamphetamine (MDMA) to restore function for patients with these disorders. The primary hypothesis is that MDMA, via prosocial effects, increases the ability of patients to address the underlying psychopathology of the disorder.
What is MDMA?
Methylenedioxymethamphetamine or MDMA is a derivative of amphetamine and a member of the phenethylamine family of chemicals that may act as stimulants, hallucinogens, and/or entactogens. It produces an energizing effect, distortions in time and perception, and enhanced enjoyment from sensory experiences. It has also been described as an entactogen—a drug that can increase self-awareness and empathy.
Methylenedioxymethamphetamine (MDMA) Pharmacology
MDMA penetrates the blood-brain barrier and interacts with several recognition sites in the brain but displays the strongest affinity for the serotonin transporter followed by the norepinephrine and dopamine transporters.
The primary effect of acute MDMA exposure is a marked elevation and increases in extracellular dopamine and norepinephrine. Most of the behavioral effects of MDMA have been attributed to effects produced by increases in these neurochemical responses, but MDMA also increases release of a number of hormones, including oxytocin, which might also explain some of the behavioral effects of MDMA.
Common effects after taking MDMA include:
- Enhanced sense of well-being
- Increased extroversion
- Emotional warmth
- Empathy towards others and self
- Willingness to discuss emotionally charged memories
- Enhanced sensory perception
A Brief Overview of MDMA in Psychiatry
Psychedelics have been explored as possible adjuncts to psychotherapy since the early part of the 20th century. The main idea behind the use of these drugs was that they would help the patient to become aware of suppressed emotions and desires, thereby making them amenable to intervention by traditional therapeutic means. Widespread illicit use and concern about potential danger caused a change in the scheduling of psychedelics that essentially ended further experimentation for several decades.
- MDMA gained a small following among psychiatrists in the late 1970s and early 1980s, despite the fact that the drug had not undergone formal clinical trials nor received approval from the U.S. Food and Drug Administration (FDA) for use in humans. Some psychiatrists believed that it enhanced communication in patient sessions and allowed patients to achieve insights about their problems. It was also during this time that MDMA started becoming more widely available on the street.
As with the earlier psychedelics, methylenedioxymethamphetamine (MDMA) was initially proposed as an adjunct to psychotherapy, but because of concerns related to abuse liability and a large number of potential adverse effects, MDMA became a Schedule 1 controlled substance in most countries under the United Nations Convention on Psychotropic Substances.
- This scheduling is for drugs with a high potential for abuse that lack currently accepted medical use in treatment. Recently, MDMA has been put forward as a potential agent in the treatmentof certain mental health and addiction disorders.
However, it has now been suggested that MDMA is effective as an adjunct to traditional psychotherapy in the treatment of posttraumatic stress disorder (PTSD) and approval for a full-scale phase 3 clinical trial has been approved by the Food and Drug Administration.
What is PTSD?
PTSD falls under the category of Trauma and Stressor Related Disorders and is defined as the emotional distress that occurs after an event involving actual or threatened death, serious injury, or a threat to physical integrity and that leads to avoidance of stimuli associated with the trauma, feelings of emotional numbness, and persistent symptoms of increased sympathetic nervous system arousal.
MDMA as a Possible Adjunct Treatment for PTSD?
MDMA has been shown to increase social interactions, decreases adverse responses to both negative facial expressions and social rejection, and increases prosocial and cooperative behaviors. It has recently been tendered as an effective adjunct to therapy for the treatment of PTSD because of the possibility to revisit traumatic memories without extreme negative emotional experiences that have traditionally caused high percentages of patients to drop out of treatment. There is evidence that MDMA might be an effective adjunct to therapy for PTSD.
- Because of the positive results of the preliminary phase 1 and 2 clinical studies of patients with PTSD, the list of disorders that might be expected to benefit from MDMA-assisted psychotherapy has expanded and now includes generalized anxiety disorders; impairments in social functioning, particularly in autism; mood disorders; and substance abuse.
There have been a small number of randomized, placebo-controlled double-blind studies to assess the effectiveness of MDMA in PTSD and funded by the Multidisciplinary Association for Psychedelic studies. A meta-analysis revealed that only 2 studies of participants who met DSM-IVR criteria for PTSD were randomized and placebo controlled. Both of the studies reported beneficial effects of MDMA.
- One study revealed that a combined treatment of MDMA and psychotherapy may be effective for treating PTSD as MDMA appears to diminish the fear response and decrease defensiveness without blocking access to memories and may facilitate engagement in therapy by strengthening the therapeutic alliance and enhancing the identification of and response to emotional states. Individuals are able to stay emotionally engaged with traumatic memories without being overwhelmed by anxiety or other painful emotions or avoiding them by dissociation or emotional numbing.
- A more recent randomized, double-blind dose-response study examined the effects of MDMA in a group of primarily male (73%) treatment-resistant veterans, firefighters, or police officers who also received psychotherapy. The study was conducted during a 5-year period. The 26 subjects were randomly assigned to 1 of 3 doses of MDMA (30, 75, or 125 mg). Additional 125-mg doses of MDMA were administered in a crossover design. In this small sample, the higher doses of MDMA produced significant improvements in PTSD that persisted for at least 12 months.
These preliminary findings are encouraging and support the idea that MDMA might be an effective adjunct to more traditional psychotherapy in that MDMA-assisted psychotherapy may help people who have experienced psychological trauma and who have not been able to resolve their problems through existing treatments.
In summary, MDMA-assisted psychotherapy is a promising approach to helping people who have experienced psychological trauma and who have not been able to resolve their resulting problems through existing treatment options. Research into its effectiveness, safety and long-term benefits is still in its infancy.
MDMA may provide a bridge to effectively overcome the gap between psychotherapy and psychopharmacology, thereby facilitating the integration of an exciting new holistic approach to psychopathology and we must not allow preconceptions, politics or puritanism or misinformation to get in the way of this.