PTSD Treatment with Psychedelic Drugs

PTSD Treatment with Psychedelic Drugs

1) Objectives

  • Understand PTSD and the symptoms it causes.
  • Learn how the chemical psilocybin, found in psychedelic drugs, can potentially help those suffering from PTSD.
  • Discuss the ethical implications of using drugs that are often used recreationally as therapeutics.

2) Curriculum Integration Ideas

This brief may be used in life or social science classes where there are units for topics including:

  • Psychology for pharmacology unit

3) Post-Traumatic Stress Disorder: An Overview

After a person experiences a traumatic or life-threatening event such as a natural disaster, a car accident, or military combat, he or she may develop a mental health problem called post-traumatic stress disorder (PTSD). While it is typical to have anxiety about the traumatic event weeks or months after, if it is still difficult to perform daily functions after that amount of time, it is likely that a person has PTSD. Sometimes treatment causes the PTSD to go away, while other times it simply goes away on its own after a period of time. The medical community diagnoses PTSD based on the following DSM criteria from the American Psychiatric Association:

Criterion A (one required): The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):

  • Direct exposure
  • Witnessing the trauma
  • Learning that a relative or close friend was exposed to a trauma
  • Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)

Criterion B (one required): The traumatic event is persistently re-experienced, in the following way(s):

  • Intrusive thoughts
  • Nightmares
  • Flashbacks
  • Emotional distress after exposure to traumatic reminders
  • Physical reactivity after exposure to traumatic reminders

Criterion C (one required): Avoidance of trauma-related stimuli after the trauma, in the following way(s):

  • Trauma-related thoughts or feelings
  • Trauma-related reminders

Criterion D (two required): Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):

  • Inability to recall key features of the trauma
  • Overly negative thoughts and assumptions about oneself or the world
  • Exaggerated blame of self or others for causing the trauma
  • Negative affect
  • Decreased interest in activities
  • Feeling isolated
  • Difficulty experiencing positive affect

Criterion E (two required): Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s):

  • Irritability or aggression
  • Risky or destructive behavior
  • Hypervigilance- an increased state of awareness that may be caused by fear and anxiety
  • Heightened startle reaction
  • Difficulty concentrating
  • Difficulty sleeping

Criterion F (required): Symptoms last for more than 1 month.

Criterion G (required): Symptoms create distress or functional impairment (e.g., social, occupational).

Criterion H (required): Symptoms are not due to medication, substance use, or other illness.
Two specifications:

  • Dissociative Specification. In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli:
    • Depersonalization. Experience of being an outside observer of or detached from oneself (e.g., feeling as if "this is not happening to me" or one were in a dream).
    • Derealization. Experience of unreality, distance, or distortion (e.g., "things are not real").
  • Delayed Specification. Full diagnostic criteria are not met until at least six months after the trauma(s), although onset of symptoms may occur immediately.

PTSD is not diagnosed unless the symptoms last for at least one month, and either interfere with work/home life or cause significant distress. Doctors diagnose PTSD by performing a physical exam to check for medical problems that could possibly be causing the symptoms. Doctors perform a psychological evaluation that includes a discussion of the signs and symptoms of PTSD and the event/events that led up to them. New imaging studies also show that PTSD can lead to lasting changes in the brain areas such as the amygdala, hippocampus, and prefrontal cortex, which are involved in the regulation of emotion, memory, and high-level functioning, respectively.

There are two types of treatment for PTSD available. One is psychotherapy, which is the use of psychological methods usually based on regular and personal interaction to help a person change in the ways that he or she would like. The main type of psychotherapy that is used to help patients with PTSD is cognitive processing therapy. The goal of this type of therapy is to teach a patient with PTSD how to evaluate and change the upsetting thoughts that they are having in the wake of their trauma. Therapists believe that when a person changes their thought patterns, he or she can change the way he or she feels. If a patient has experienced a traumatic event, psychotherapy can change the way he or she thinks about or sees the world.
Cognitive processing therapy teaches patients new and helpful ways to look back on and think about their trauma. Patients often blame themselves for what happened, and therapists help patients try to look at their experiences from a new perspective. Most of the time, patients are taken to an office where they are met by a mental health professional. In other situations, patients attend group therapy sessions in which all the patients present are suffering from PTSD.

Another way to treat PTSD is through the prescription of antidepressants. Antidepressants have effects on the hippocampus, an area of the brain involved in memory formation, that counteract the effects of stress. There are two types of antidepressants: SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors). The four main antidepressants effective for treating PTSD are:

SSRIs:

  • Sertraline (Zoloft)
  • Paroxetine (Paxil)
  • Fluoxetine (Prozac)

SNRIs:

  • Venlafaxine (Effexor)

Lastly, three new antipsychotic drugs are being used to help treat PTSD: olanzapine, quetiapine, and risperidone.

4) Can Psilocybin Help?

While therapy, antidepressants, and antipsychotics have shown to help patients, many times these methods fall short, leaving patients to continue suffering from PTSD. Studies have suggested that anti-depressants do not work so well for people who have had multiple traumas or chronic PTSD, over the course of years. A new study found that risperidone, the antipsychotic medication used to help some PTSD patients, worked no better than a placebo in alleviating typical PTSD symptoms in patients who had been suffering from the disorder long-term or who continued to suffer symptoms after being treated with antidepressants. Because the use of many of these drugs may result in intolerable side effects, many patients are left to suffer through PTSD with no sign of relief. Many of these patients turn to substance abuse, develop anger management issues, and/or commit suicide. A study analyzing data from the National Comorbidity Survey, a nationally representative sample, showed that out of six anxiety diagnoses, PTSD was significantly associated with suicidal attempts.

There is some evidence in animal studies to show that psilocybin, the psychedelic compound found in “‘magic mushrooms”’ may act on stimulating nerve cell regrowth in parts of the brain responsible for emotion and memory. A study from the University of South Florida in 2013 found that psilocybin stimulates neurogenesis: the growth and repair of brain cells in the hippocampus (the brain’s center for emotion and memory). In the study, mice that were given psilocybin overcame fear conditioning far better than mice that were given a sham drug. The study supported the hypothesis that psilocybin can help break the traumatic cycle that occurs in patients with PTSD.

Stephen Ross, a psychiatrist at NYU, conducted a study on terminally ill cancer patients using a two-arm clinical trial, and he found that one-time treatment of psilocybin very quickly brought relief from distress that lasted over six months in 80% of the study subjects that were monitored. For the study, half of the participants were randomly assigned to receive a 0.3 milligrams/kg dose of psilocybin. The rest received a control drug of 250 milligrams of niacin, which is known to produce a “rush” similar to one associated with a hallucinogenic drug experience. Halfway through the study period (7 weeks), all of the participants switched treatments. Neither the researchers nor the patients knew which patients had first received psilocybin or which received the control. The control group and double-blind procedures maximized the validity of the results of the study. All of the patients, mostly women aged 22 to 75, had advanced gastrointestinal, blood, or breast cancers. All had been diagnosed as having serious psychological distress that was related to their disease. The researchers concluded that if psilocybin could reduce psychological distress in terminally ill cancer patients, it could apply to less extreme medical conditions related to psychological distress as well. Patients noted that after being treated with psilocybin, they felt their quality of life improve. They noted that they wanted to engage more with external activities, had more energy, experienced improved relationships with their family members, and performed better at work.

Ross says that the findings “…have the potential to transform the care of cancer patients with psychological and existential distress, but beyond that, it potentially provides a completely new model in psychiatry of a medication that works rapidly as both an antidepressant and anxiolytic and has sustained benefit for months.” Ross has hope that the drug will become legal in the next five years. “If larger clinical trials prove successful, then we could ultimately have available a safe, effective, and inexpensive medication—dispensed under strict control—to alleviate the distress that increases suicide rates among cancer patients,” he says.

Ross noted that psilocybin may even lead to “inverse PTSD,”, a profoundly positive memory that affects participants for months, much like a severe trauma might in post-traumatic stress disorder. Ross means that the patients could recount their psilocybin experience the same way they recount their traumatic experiences, except in a positive rather than negative way. The psilocybin experience leaves lasting positive effects on the patient, similar to the way a traumatic experience leaves lasting negative effects on the patient. Psilocybin has not only been given to patients with PTSD, it has been given to terminally ill patients with a certain amount of time left to live, according to their prognoses well.

After the study, patients reported that their psilocybin experiences felt spiritual. Many described the experience as being “bathed in God’s love” or being “full of love.” They describe that their minds were opened with the drug and that it gave them a new perspective on life. Terminally ill patients claim to no longer feel death because they felt connected to the universe in a way they had never experienced in the past. Researchers and supporters of the drug believe that because the drug can give people such a different and positive perspective, the patients would not lose this new perspective, which would explain while the positive effects last over six months a lot of the time. Because these psilocybin experiences are oftentimes profound and life-changing, the drug gives people the opportunity to permanently change the way they think about and see the world.

The Debate

There are reasons why psilocybin could be a safe and effective treatment for PTSD.
What are the pros and cons of approving such a treatment?

For

The supporters of using psychedelic drugs to help patients lessen their anxiety feel strongly that these drugs should be able to be legally given in a safe and supportive medical setting. In Stephen Ross’s study, the majority of participants reported having a positive experience that helped them feel less afraid. One could ask: If these drugs can have such a success rate, then what could possibly be the reason for them not being legal?

Secondly, drugs can be either chemically addicting or psychologically addicting. When the cells in a person’s body cannot function without a certain drug, that person is chemically addicted to the drug. On the other hand, when one is psychologically addicted to a drug, they think that they desperately need it in their heads, but their body doesn’t actually physically need it to function. Psilocybin is not chemically addicting like other drugs, such as nicotine. Psilocybin is also known to have no strongly harmful negative effects.

Utilitarianism is a doctrine used in ethics that says that “an action is right insofar as it promotes happiness, and that the greatest happiness of the greatest number should be the guiding principle of conduct.” When drugs are in the process of being approved, the FDA uses this doctrine to weigh the pros and cons in order to see if the drug will lead to the greatest overall happiness. Supporters believe that because the drug is not that bad for you and has shown to have positive effects, the good definitely outweighs the bad.

Against

The strongest argument against the cause is the chance of a “bad trip,” or a scary or anxiety-inducing experience when feeling the psychoactive effects of the drug. This usually happens when the patient does not feel safe, or feels uncomfortable in some way. Potentially, a bad trip could mentally scar the individual who experiences it. People who take psychedelic drugs have also reported experiencing flashbacks, or the feeling as if they are experiencing a trip on a psychedelic drug when they are not. This can be dangerous in certain situations, like when operating a motor vehicle. Also, while it has not been shown that psychedelic drugs have any serious health concerns, there are physical effects of psychedelic drug use that can be dangerous. These effects include: an increase in heart rate in blood pressure, an increase in body temperature, loss of appetite, nausea and vomiting, and muscular issues. There are also studies that show that patients do not experience any strong positive effects from being given the drug.

If the drug does in fact get approved, it will need to be tested in clinical trials.  There are many dangers and risky situations that arise when clinical trials become involved with new drugs. For example, how can a patient who has never taken a psychedelic drug consent to taking it if they don’t know the ways in which it could affect them? This can cause problems from a legal perspective, which is concerned with patient safety and protection.

If psilocybin is as helpful as supporters say, then patients besides ones suffering from PTSD would want to take the drug as well. Patients suffering from different types of anxiety and other issues will be eager to access the drug. If so many patients want to try the drug, a new way to regulate the legal use of the drug will become necessary.

Can you think of others ideas? What other good can come out of patients being given the opportunity to take these drugs? What risks could the drug potentially cause?

Class Activity

Read aloud: A new pill has been made that helps people lose five pounds every time they take it. The weight loss community is going crazy about this new miracle drug—begging for the FDA to finally approve it so that people can lose weight instantly and feel more confident. But there are drawbacks—taking the drug leads to increasing risk of many diseases, including heart disease. The drug also makes you age faster. Lastly, the drug takes away all appetite, so much so that it is difficult for a person who is taking the drug to get their daily nutrients from food.

Split the classroom into two groups. Half the class will be lawyers arguing for the drug’s approval, and the other half will be the FDA listening and responding with concerns. Whose arguments will be stronger?

This brief was written by Bella Ratner as part of the 2017 Summer Internship Program at the Division of Medical Ethics.

References and Further Reading

Off-Site Resources

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Research
Neuroethics