From Counterculture Symbol to PTSD Treatment: The Journey of Psychedelics

Anton Gulko for Health Empowerment Coalition

Posttraumatic Stress Disorder (PTSD) is a chronic anxiety disorder that can develop after exposure to a traumatic event. Nearly 90% of the US population reports experiencing at least one traumatic event during their lifetime, including sexual assault, driving accident, combat, or a natural disaster.¹ Although the majority of trauma-exposed individuals will not develop PTSD, several studies estimate that about 8% of the US population, a disproportional number of whom are from communities of low-socioeconomic status, will experience PTSD at some point in their lives.² In addition to histories of trauma, PTSD is characterized by chronic, distressing symptoms such as flashbacks, avoidance, survivor’s guilt, numbness, irritability, and sleep disturbance.²

Due to the high prevalence and persistence of symptoms, PTSD has been the subject of hundreds of clinical studies aimed to identify effective treatment strategies. Some of the treatments that are worth mentioning include serotonin reuptake inhibitors, SSRIs, and trauma-focused psychotherapies. SSRIs are a type of antidepressant used to alter the biochemical state of the brain. They work by increasing serotonin levels, which is a neurotransmitter thought to have a positive effect on mood and emotion. On the other hand, trauma-focused psychotherapies encompass a group of therapies used to alter cognitive state - the way we think. One such therapy, exposure-based intervention, focuses on gradually exposing the patient to memories of the traumatic events in a safe and controlled environment as an attempt to disassociate those memories from feared consequences such as physical harm in cases of past physical assault.³

Unfortunately, just like in many other aspects of medicine, some treatments work for some people, but no one treatment seems to work for everyone. Despite being commonly prescribed for anxiety disorders, nearly half of the participants enrolled in clinical trials to treat PTSD fail to respond to treatments including SSRIs and psychotherapies.⁴ Taken together, these data suggest that there is a vast number of patients who fail to respond to traditional treatments and continue to live in distress. This, in turn, has pushed researchers and physicians to look for alternative treatments, with many shifting their attention to the use of psychedelics.

The idea of treating psychological disorders with psychedelics is not new; psychedelics have been around for decades and even centuries in some cultures. Before PTSD was even formally established as a psychiatric disorder in 1980, a Dutch psychiatrist Jan Bastiaans had successfully experimented with using psychedelics to treat hundreds of veterans suffering from long-term psychological consequences of World War II.⁵ However, the legal prohibition of a large number of psychedelic drugs halted most of such research until more recently. The momentum has picked up dramatically and once a symbol of deviance, psychedelics are now being tested for use in psychiatric conditions in 17 clinical trials, a noticeable jump from just 2 FDA-approved clinical trials in 2016.⁶

So what are psychedelics and how do they work? Psychedelics are a group of drugs that share common consciousness-altering effects. In some cases, they involve temporary hallucinations and altered sensations. Some, like LSD and MDMA, also known as Molly, are synthetically made in a laboratory; while others, like psilocybin, are found in nature, specifically in several species of fungi.¹⁰ The exact mechanisms of action of these drugs are still debated, however, it is known that their effect on the brain's biochemistry is similar to that of SSRIs. Psychedelic drugs act to increase the brain's serotonin levels, but do so by a mechanism that is more potent and short-lived than the traditional antidepressant.

The connection between PTSD and psychedelics may not be intuitive at first glance, however, further deliberation makes the link clearer. PTSD treatment relies on getting a patient to recall traumatic events over the course of several therapy sessions to extinguish the fear associated with them. However, this method poses challenges for patients who have those memories repressed (blocked off) or who experience extreme emotional distress during their recollection. Studies suggest that MDMA reduces the fear response by inhibiting the part of the brain responsible for negative emotions.⁷ Combined with the increased levels of serotonin, this allows patients to recall traumatic events, in detail, without those experiences being “hijacked by fear.” ⁴

Now that we have established the potential benefits of psychedelics, let’s take a closer look at how they are being incorporated into PTSD treatment. According to Reiff et al. (2020), three types of sessions are employed in psychedelic-assisted psychotherapy (PAP). During preparatory sessions, a therapist helps the patient understand their condition and symptoms, emphasizing the potential emotional and psychological growth that can result from PAP. The therapist also educates the patient on the nature of a psychedelic state. During medication sessions, the patient ingests a drug and is encouraged to aim her or his attention inwards. For the next 6-8 hours the patient is guided through her or his experience by a therapist who provides safety, comfort, and unconditional positive regard. Finally, during integration sessions, the therapist works with the patient to interpret the content of the psychedelic experience. This often involves identifying insights and reframing negative thoughts about the trauma in a manner that would translate into meaningful long-term changes in the patient’s emotional and psychological states.⁸

Despite the current wave of interest in PAP, translating these findings into widely available treatments will be challenging. These challenges can be split roughly into two categories: efficacy and implementation. As we briefly touched on earlier, the exact mechanisms of how these drugs work in the brain still need further research. While some aspects of psychedelic drugs, like addictiveness, have been well-documented, more research is needed to identify the differential effects of these drugs on people of different ages, races, and socioeconomic statuses.¹¹ Moreover, the ongoing clinical trials, while large in number, are limited in size. Due to these drugs being tightly regulated, the clinical trials often only enroll between a couple of dozen and a couple of hundred participants. This has a detrimental effect on the applicability of these studies, particularly whether or not these results can be generalized to a larger population.6 Likewise, the novelty of PAP will require the training of thousands of therapists in order to be implemented on a large scale.

There is still a lot left to learn about the potential therapeutic benefits of psychedelics, but the existing research is promising and merits further clinical evaluation. While the majority of ongoing clinical trials focus on treating people with severe PTSD, several studies evaluating the effectiveness of psychedelics for major depressive disorders showed that 71% of participants had significant improvements after just 4 weeks of treatment.⁹ Potential generalizability of psychedelics for treating a wide range of psychiatric conditions would benefit those unresponsive to traditional treatments and provide a broad new area of research in the field of psychotherapy.

References:

1. Kilpatrick D., Resnick H., Milanak M., Miller M., Keyes K., Friedman M. National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. J. Trauma. Stress. 2013; 26:537–547. DOI: 10.1002/jts.21848

2. Lancaster, C. L., Teeters, J. B., Gros, D. F., & Back, S. E. Posttraumatic Stress Disorder: Overview of Evidence-Based Assessment and Treatment. Journal of clinical medicine. 2016; 5(11), 105. DOI: 10.3390/jcm5110105

3. Leuchter A., Cook I., Marangell L., Gilmer W., Burgoyne K., Howland R., Trivedi M., Zisook S., Jain R., McCracken J., Fava M., Iosifescu D., Greenwald S. Comparative effectiveness of biomarkers and clinical indicators for predicting outcomes of SSRI treatment in Major Depressive Disorder: Results of the BRITE-MD study, Psychiatry Research. 2009; Volume 169, Issue 2, Pages 124-131. DOI: 10.1016/j.psychres.2009.06.004

4. Maxmen, A. Psychedelic compound in ecstasy moves closer to approval to treat PTSD. Nature. 2017. DOI: 10.1038/nature.2017.21917

5. Krediet, E., Bostoen, T., Breeksema, J., van Schagen, A., Passie, T., & Vermetten, E. Reviewing the Potential of Psychedelics for the Treatment of PTSD. The international journal of neuropsychopharmacology. 2020; 23(6), 385–400. DOI: 10.1093/ijnp/pyaa018

6. Tullis, P. How ecstasy and psilocybin are shaking up psychiatry. Nature. 2021; 589, 506-509. DOI: 10.1038/d41586-021-00187-9

7. Young, M. B., Andero, R., Ressler, K. J., & Howell, L. L. 3,4-Methylenedioxymethamphetamine facilitates fear extinction learning. Translational psychiatry, 2015; 5(9), e634. DOI: 10.1038/tp.2015.138

8. Reiff C., Richman E., Nemeroff C., Carpenter L., Widge A., Rodriguez C., Kalin N., McDonald W. Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry. 2020; 177:5, 391-410. DOI: 10.1176/appi.ajp.2019.19010035

9. Davis AK, Barrett FS, May DG, et al. Effects of Psilocybin-Assisted Therapy on Major Depressive Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2021; 78(5):481–489. DOI: 10.1001/jamapsychiatry.2020.3285

10. NIDA. 2019, April 22. Hallucinogens DrugFacts. Retrieved from https://www.drugabuse.gov/publications/drugfacts/hallucinogens on 2021, November 2

11. Aday J., Davis A., Mitzkovitz C., Bloesch E., Davoli C. Predicting Reactions to Psychedelic Drugs: A Systematic Review of States and Traits Related to Acute Drug Effects. ACS Pharmacology & Translational Science. 2021; 4 (2), 424-435. DOI: 10.1021/acsptsci.1c00014

Author: Anton Gulko

Edited by: Maggie Sell, Mateya Rettig, and Michelle Pan

The Health Empowerment Coalition is a student-led organization that aims to empower individuals across the United States to improve their health literacy and take charge of their health. The views expressed in this article are the authors’ own and do not reflect the official opinions of the institutions at which they work and study. Additionally, the content in this article is not intended to provide medical advice.