Post-traumatic stress disorder (PTSD) is the result of exposure to experiences that have involved death. Or in any case a threat to his own physical integrity or others, in which the person has tried a response of fear and impotence. As a consequence of the event, the person:
- experiences intrusive symptoms related to the event, for example nightmares or flashbacks;
- It tends to avoid everything that is connected to the traumatic event both in terms of thoughts, memories as well as places or people;
- He manifests alterations of Arousal as difficulties in falling asleep, irritability, hypervigilance;
- Finally, it presents negative alterations of thoughts and emotions associated with the event with consequent negative knowledge of themselves, on others and the world.
PTSD: the disorder of memory
According to the adaptive information processing model (AIP, Shapiro 2000), the biochemical responses triggered to face the traumatic event block the innate system of the brain for information processing. They therefore leave the information connected to the trauma isolated, trapped in a neural network with the same emotions, beliefs and physical sensations that had been activated at the time of the event.
In this sense theexperience is not processedremaining stored as it was lived, and is not integrated with the rest of the experiences.
What characterizes the PTSD is to continue having the same misunderstanding reactions, even after some time, as if the person continued to relive the event in the present moment.
Since the event is something that has already happened is no longer the event in itself that the person is disturbing, but rather the memory of the event. That is to say how the event was stored with thoughts, emotions, physical sensations experienced at the time when the trauma happened.
Post traumatic stress disorder treatments
Psychotherapy can certainly not change the patient’s history or help it erase the event from memory, how much to allow a reorganization of the traumatic event within the neural networks in such a way that that event no longer disturbances and indeed can turn into an experience of post-traumatic growth.
The treatments Evidence-Based For PTSD, such as EMDR therapy (Shapiro, 2000) and prolonged exposure treatment (Foa, Hembae & Rothbaum, 2007), they pursue this objective by exposing patients to those traumatic events source of terror and horror.
Sometimes exposure to traumatic material can be ‘too’ for the person because it activates a physiological reaction that exceeds the subject’s ability to tolerance.
For this reason, researchers and clinicals have started studying whether specific drugs can intervene in facilitating patients to access traumatic experiences without feeling overwhelmed.
Can Ecstasy increase the tolerance window?
The word ecstasy immediately evokes images of young people at the rave parties who use drugs for recreational use and yet the chemical compound 3.4-theiledioximetamine (MDMA). That is to say the psychoactive substance at the base of the ecstasy. This is gaining credibility as potential supplementary treatment for patients who have undergone serious trauma.
In a recent article published in the magazine Nature MedicineMitchell and collaborators (2021) have shown that three doses of MDMA, administered together with a psychotherapy treatment, over 18 weeks were in a significant decrease in the symptoms of post-traumatic stress disorder and in an improvement in general functioning with a significant reduction in depressive symptoms.
These data illustrate the potential benefit of combined psychotherapy with MDMA with respect to pharmacotherapy with sertraline and paroxetine (SSRI antidepressants) which, as indicated by the authors, is ineffective in 40-60% of cases of patients with post-traumatic stress disorder.
The recent study
Mitchell’s study et al. (2021), financed by Multidisciplinary Association for PsychCelic Studies (Maps), is a multicenter study that took place in 15 different sites between the United States, Canada and Israel. He included 91 patients with severe and persistent post-traumatic stress disorder, who have been randomized to receive either a treatment with MDMA or a placebo together with psychotherapy.
Neither the participants nor the researchers knew who the psychoactive drug had been administered to who had been administered.
At the end of the study, 67% of patients who had received MDMA in combination with psychotherapy no longer satisfied the criteria for post-traumatic stress disorder. Compared to 32% of those who had received a placebo with psychotherapy.
In addition, it was found that 88% of patients in the experimental arm (MDMA + Psychotherapy) had a significant reduction in symptoms, while this percentage fell to 60% in the control group.
Being a phase III study, it represents the last stage of experimentation before obtaining approval for clinical use. In fact, the Food and Drug Administration of the United States will approve the psychotherapy assisted by MDMA by 2023.
What is the contribution of MDMA to psychotherapy?
The idea that psychedelic drugs and psychotherapy work in synergy raises complex issues on how to optimize the use of a psychoactive substance.
As the MDMA, and other strictly controlled psychedelic compounds, approach the regulatory approval, careful supervision by therapists can help overcome their reputation of illegal substances and fears of indiscriminate use.
It is not yet completely clear how the MDMA on the brain works. PTSD patients are characterized by one Hyperactivity of the amygdala (the brain area involved in fear) and areduced activity of the prefrontal cortex. As well as the hippocampus, namely the region of the brain in which long -term memories are kept.
The MDMA seems to induce a series of changes in the brain by reducing the activity of the amygdala, increasing the activity of the prefrontal cortex and increasing the connections between the amygdala and the hippocampus in order to leave the traumatic memories of the past in the long -term memory.
The psychoactive drug also increases chemicals such as serotonin and oxytocin and this can lead to a state characterized by a greater sense of safety and social connectionin addition to increasing compassion towards itself.
How the MDMA works in the treatment of the PTSD
The clinical hypothesis is that the pharmacological properties of the MDMA, if associated with psychotherapy, can generate a large enough tolerance window to allow participants to rethink and reprocess the traumatic material without feeling overwhelmed or hindered by emotional discomfort, both in terms of hyperactivation and hypotivation.
MDMA therapy can in fact facilitate access to traumatic memories with greater self -compression and with reduced levels of anger and shame.
In addition, the interpersonal and prosocial effects of the MDMA can support the quality of the therapeutic alliance, an important factor connected to adherence to treatment and therefore to the therapeutic result.
In summary, therefore, the MDMA could be a facilitator of the psychotherapeutic treatment since it allows access to the traumatic material to those who would experience it as ‘too much’.
MDMA is not a panacea
There is no doubt that these results have aroused a profound interest from the scientific community and public opinion and have also been accepted with great enthusiasm by a part of it.
Even Barbara Rothbaum, Clinical Psychologist at Emory University, spoke of a new one zeitgeist in psychiatry.
The research certainly offers a new direction and these developments can be very interesting in considering the MDMA a promising candidate in treatment of post-traumatic stress disorder.
The legitimate skepticism
Nonetheless, there is some skepticism in the scientific community with respect to considering the MDMA a revolutionary treatment. Below it is appropriate to indicate a whole series of critical issues of Mitchell’s study and coll. (2021) who at the moment move us from the idea of a panacea for the PTSD:
- The results of the study are based only on 91 people and so we would need studies with much more numerous champions in order to confirm what emerged.
- Being an self -selection (patients in fact have voluntarily chosen to participate in the study), may not be representative of all trauma survivors. Patients who volunteered to take part in the study probably had an existing interest in the drug and, although the study used a placebo group to help correct the effect of positive expectations, it could be difficult to be able to make someone ‘blind’ on the fact that a drug like MDMA has been administered.
- Another consideration has to do with the fact that manualized psychotherapy in the study does not represent one of the recognized psychotherapy approaches like Evidence-Based in the treatment of the PTSD. This makes it difficult to say if psychotherapy associated with MDMA works better than only psychotherapy focused on trauma. In this regard, it would be interesting to be able to test the MDMA together with psychotherapy of evidence recognized for the PTSD, such as EMDR therapy (Shapiro, 2000) or the prolonged exposure treatment (Foa et al., 2007).
- Finally there is a big difference between a highly controlled research study with a limited number of participants and the complexities of real clinical work. For example, many psychiatric or medical conditions that many patients have are excluded from clinical studies.
Conclusions
In conclusion, although the MDMA cannot be defined as the cure for the PTSD, the incontrovertible data of the effectiveness of the psychotherapy treatment together with the MDMA remains and this result supports the growing conviction that the drugs that produce psychedelic effects have a real potential in the treatment of serious psychopathological disorders.
Bibliography
- Foa E. B, Hembree, EA, & Rothbaum, Bo (2007). Prolonged Exposure Therapy for Ptsd: Emotional Processing of Traumatic Experiences: Therapist Guide. Oxford University Press.
- Mitchell, JM, Bogenschutz, M., Lilientein, A. et al. (2021). MDMA-Assisted Therapy for Severe Ptsd: in Randomized, Double-Blind, placebo-Controlled Phase 3 Study. Nature Medicine, 27, 1025–1033.
- Shapiro, F. (2000). EMDR, desensitization and reworking through eye movements. Milan: Mcgraw-Hill.
