MDMA Assisted Psychotherapy for Treating PTSD & Addiction

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In the 2013 article, ”Can MDMA Play a Role in the Treatment of Substance Abuse?” by Lisa Jerome*,1 and Shira Schuster2 and B. Berra Yazar-Klosinski1 they report that in 2010, ”an estimated 23.1 million individuals aged 12 years or older (9.1%) needed treatment for a substance abuse disorder, while only approximately 11.2% of those needing treatment (approximately 1% of the general population over 12 years old) received treatment [1].”

MDMA-assisted psychotherapy for the treatment of addiction just might bring the much-needed relief of treating substance abuse to millions. Through rigorous scientific research, psychedelics like psilocybin and LSD's effectiveness for treating addiction has been revealed. ”A recent meta-analysis of randomized, double-blind, controlled studies suggests that people diagnosed with alcoholism reduced alcohol use after a single exposure to LSD [12].” Since MDMA is an entheogen that is similar enough in effect to psychedelics, researchers began to wonder if MDMA may also play a role in addiction treatment. Like an old married couple, addiction and trauma are intricately tied. So too, separating the effects of MDMA-assisted psychotherapy and psychedelic-assisted psychotherapies on addiction and PTSD may prove to be a challenging if not impossible task. However, because trauma and addiction are so causational, it may not be necessary to tweeze the two apart when it comes to finding effective treatments. What treats one, will naturally affect the other. 

MDMA's value in assisting psychotherapy is not new on the scene. Lisa Jerome and Shira Schuster et al. inform, ”MDMA was used by some psychotherapists as an adjunct to psychotherapy, prior to becoming a Schedule 1 controlled substance due to extensive use in non-medical settings [15, 17-19]. In the late 1970s and early 1980s, therapists around the U.S. combined MDMA with psychotherapy to address neuroses, relationship difficulties, psychological problems, and PTSD [20, 21].” Because of MDMA's euphoric effects, the biggest concern posed for the use of MDMA in addiction treatment is its potential for being an addictive substance itself. The article, ”Can MDMA Play a Role in the Treatment of Substance Abuse?” posits, ”While MDMA appears to be a promising treatment for at least one psychiatric disorder when combined with psychotherapy, it also possesses moderate abuse potential.” And yet other studies have supported the notion that intention for its use as a therapeutic drug may minimize if not void its potential to trigger addiction. Authors point out, ”In another study of MDMA-assisted psychotherapy in people with PTSD, urinary drug screens taken during follow-up assessments were all negative [26].” While euphoria will undoubtedly be part of the experience, during an MDMA facilitated psychotherapeutic session clients may experience a range of emotions, including painful or fearful memories. This challenging faucet of the MDMA psychotherapeutic use, in theory, mitigates the risk of future repeat "high" seeking behavior. 

How Does MDMA Work to Treat Substance Abuse? 

MDMA decreases activity in the amygdala, the part of the brain that detects threats. With the amygdala less active, feelings of fear are reduced. MDMA affects facial expression threat signals, decreasing the subjects' ability to detect anger on the faces of those around them. This decrease in facial threat expression perception means the subject feels more trusting, open, and close to the people around them and therefore more likely to open up about their trauma. In couples therapy, it means that the defenses which have built up between the couple come down. In the article MDMA-assisted psychotherapy for PTSD: Are memory reconsolidation and fear extinction underlying mechanisms? they explore the specific actions MDMA has on brain activity.”Studies in healthy individuals have demonstrated that MDMA mediates emotional memory processing. MDMA reduced left amygdala response to angry facial expressions (Bedi et al., 2009) and caused unpleasant memories to be rated as less negative, visualized as less activation of the left anterior temporal lobe and greater activation of the superior frontal gyrus/dorsal medial prefrontal cortex (Carhart-Harris et al., 2014).”  

Studies show that MDMA increases empathy and prosocial behavior. The exact mechanism of this function is still being investigated. We do know that MDMA increases both serotonin (the feel-good hormone) and oxytocin (the bonding hormone). Studies done on rodents with MDMA and an oxytocin receptor agonist that blocks the production of oxytocin, have shown no increase in prosocial behavior. This points to MDMA's action of increasing oxytocin as the key feature for the prosocial aspect. Oxytocin alone has decreased self-administration of methamphetamine in rodents which has led to the proposal of Oxytocin itself as a potential treatment for substance abuse and PTSD. While many studies point to MDMA's action on decreasing amygdala and hippocampus activity, some studies do show increases in anxiety. With the amygdala quiet, it seems unlikely that an increase in anxiety would be chemical. Nevertheless, Lisa Jerome and Shira Schuster et al. assert, "MDMA produces increases in positive mood, energy, and anxiety, and like psychedelics, it induces altered perception, which can include viewing events, thoughts or feelings in a new way [22, 45].” 

Could it be that MDMA's action of increasing activity in the dorsolateral prefrontal cortex (DLPFC) stimulates memory recall which facilitates the unearthing of traumatic memories to be processed? In this process, an increase in anxiety may be a natural byproduct, however much less than it would be to relive the traumatic event unassisted by the MDMA. According to Wikipedia, ”An important function of the DLPFC is the executive functions, such as working memory, cognitive flexibility,[9] planning, inhibition, and abstract reasoning.[10] However, the DLPFC is not exclusively responsible for the executive functions. All complex mental activity requires the additional cortical and subcortical circuits with which the DLPFC is connected.[11] The DLPFC is also the highest cortical area that is involved in motor planning, organization and regulation.[11]” 

A Shortcut to Classical Conditioning - Exposure Therapies 

Horses are prey animals with an enormous amygdala. For this reason, horses live in a heightened state of fear much of the time. They need this fear detection superpower in the wild so they can detect the presence of a predator early enough to have a chance at getting away. In the human-horse world, there is a common practice of desensitization. When a horse is scared of something, which could be anything from the sound a tarp or plastic bag makes to a riding lawn mower, the more exposure to the scary object the better. It's not safe for humans to be around horses that spook at the drop of a hat because they are upwards of a thousand pounds. If they get so scared they run in a panic, the handler might get run right over. To minimize this risk, the handler will intentionally expose them to the scary object, wait for their fear response to relax ever so slightly, and then retreat from the scary object, take a short break and then go back to the scary object again. The repetition of this process allows the horse to make new associations with the scary object. After they have been exposed to it a hundred times and their handler was right there with them to protect them, they learn that it's not a scary object after all and trust is built.

There is a similar process for treating PTSD, called Classical Conditioning. In the article MDMA-assisted psychotherapy for PTSD: Are memory reconsolidation and fear extinction underlying mechanisms?, they explain "The process of learning through repeated exposure to the conditioned stimuli without encountering the unconditioned stimuli is known as extinction and leads to reduction in the fear response while leaving the original fear memory intact (Ponnusamy et al., 2016).” Imagine a war veteran who has just returned home from Iraq walking down the street and immediately hits the deck when he hears the sound of a car backfiring. This is a conditioned reaction related to trauma. This same veteran will need to be exposed to many sounds like this without anything around him blowing up or anyone getting shot to recognize he is now safe even in the presence of sudden loud noises. Expounding on this, the article explains ”Exposure therapies used to treat PTSD aim to extinguish fear by presenting fear-triggering cues in imaginal narratives and reality-based situations while the person is in a safe setting.”

The effects MDMA has on memory recall coupled with the feelings of euphoria and safety that accompany it allows for this exposure therapy to unfold throughout one treatment. When the clients can recall traumas that happened a decade ago as if they occurred just yesterday and process them without the triggered fear response, without feeling unsafe, the effects are lasting. ”In context of PTSD treatment, the authors suggest that reducing details of emotional events may be advantageous to re-encode trauma memories with novel emotional associations.” (Allison A. Feduccia a, Michael C. Mithoefer, 2018) ”Hypothetically, when trauma memories are retrieved while under the influence of MDMA during therapy, a strong prediction error is generated by the unique internal state of MDMA-stimulated elevation of neurochemicals/hormones and the supportive therapeutic setting. This mismatch of experience, i.e. recall of memory with strong fear/anxiety vs. recall with additional emotions such as love or empathy, would allow for an update of information through molecular mechanisms.”

Life Stories, Personality and Memory Reconsolidation

Epictetus said, ”Circumstances don't make the man, they reveal him to himself.” Similarly, esteemed personality psychologist Dan Mcadams tells us that our personality resides in how we tell our life stories and the meaning we give to the events of our lives. Memoirist William Maxwell is quoted in the book, Mistakes Were Made (but not by me), "What we...refer to confidently as memory... is really a form of storytelling that goes on continually in the mind and often changes with the telling." Memory research has revealed that memory is subjective and dependent on self-concept, confirmation bias’ and the avoidance of cognitive dissonance. Personality has been shown in large part to be genetic. Through genetics and epigenetics, our family stories about the way we see ourselves in the world are passed on to us. Studies have shown entheogens have the power to change our epigenetics; the codes on top of our genes. Could it be that this happens by giving us access to a new way of telling our story? MDMA-assisted psychotherapy supports us in doing just that through memory reconsolidation. The article MDMA-assisted psychotherapy for PTSD: Are memory reconsolidation and fear extinction underlying mechanisms? explains it this way, ”The term, memory reconsolidation, describes a type of neuroplasticity that involves the process of an established memory being reactivated, destabilized, and then modified or updated with additional information.” Furthermore, ”Once a memory becomes destabilized and labile during a therapy session, MDMA may influence activity in neurocircuitry necessary for learning and memory.” This approach is based on observations that the pharmacological effects of MDMA in this setting facilitate a variety of therapeutic experiences. These typically include reprocessing of traumatic memories with clearer recall and increased equanimity without emotional numbing or dissociation.“

Belonging

The need to belong is one of the most fundamental aspects of our well-being. In Elliot Aronson's book, The Social Animal, he writes about the consequences of a lack of belonging, “On a less extreme level, feeling socially disconnected can cause people to lose the ability to regulate their emotions and control their attention, behavior, and impulses. Rejected, isolated students tend to do worse on tests, eat more junk food, and behave more aggressively than do students who feel part of a group.” It should be argued that Aronson's examples are just the tip of the iceberg. Some people may eat more junk food, others may inject heroin, smoke crack, or imbibe large amounts of alcohol. The bottom line is that feeling that one doesn't belong deregulates emotions and often leads to self-destructive behaviors. The closeness, lack of social anxiety, and connection one feels while undergoing MDMA-assisted psychotherapy begin to open the door to social belonging. People feel accepted and seen for who they truly are. Just a few hours of experiencing this can have an enormous impact on the individual's overall sense of belonging. The article Can MDMA Play a Role in the Treatment of Substance Abuse? asserts, “People report experiencing greater compassion, feelings of sociability, closeness and empathy for others and themselves while under the influence of MDMA [39, 52, 65, 68-70].” 

A renaissance of the effects of MDMA-assisted psychotherapy on PTSD, addiction, and couples therapy is well underway. In stage three clinical trials, the compound's unique impact on memory reconsolidation, reduction in fear response, feelings of closeness, and self-compassion is evidenced in helping individuals rewrite their narratives and the meanings they give to the traumatic events of their lives. This aid in assisting people to process and re-code their painful experiences is promising for the treatment of PTSD and addiction therapy alike. The sense of belonging that one feels during the MDMA-assisted psychotherapy sessions ripples out into real-world social confidence and self-acceptance. 


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