Medical cannabis shows ‘real promise’ in the treatment of PTSD

Research is still ongoing, but medical cannabis has shown real promise in the treatment of PTSD, writes psychiatrist and cannabis prescriber, Dr Niraj Singh.

Post traumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape or who have been threatened with death, sexual violence or serious injury.

PTSD has been known by many names in the past, such as “shell shock” during the years of World War I and “combat fatigue” after World War II, but PTSD does not just happen to combat veterans. 

PTSD can occur in all people, of any ethnicity, nationality or culture, and at any age. It is estimated that six per cent of the world’s population will have PTSD at some point in their lives.

People with PTSD have intense, disturbing thoughts and feelings related to their experience that last long after the traumatic event has ended. They may relive the event through flashbacks or nightmares; they may feel sadness, fear, or anger; and they may feel detached or estranged from other people. 

People with PTSD may avoid situations or people that remind them of the traumatic event, and they may have strong negative reactions to something as ordinary as a loud noise or an accidental touch.

A diagnosis of PTSD requires exposure to an upsetting traumatic event. However, the exposure could be indirect rather than first-hand. For example, PTSD could occur in an individual learning about the violent death of a close family or friend. It can also occur as a result of repeated exposure to horrible details of trauma such as police officers exposed to details of child abuse cases.

What are the symptoms?

Symptoms of PTSD fall into four categories. Specific symptoms can vary in severity.

Intrusion: Intrusive thoughts such as repeated, involuntary memories; distressing dreams; or flashbacks of traumatic events. Flashbacks may be so vivid that people feel they are re-living the traumatic experience or seeing it before their eyes.

Avoidance: Avoiding reminders of the traumatic event may include avoiding people, places, activities, objects and situations that may trigger distressing memories. People may try to avoid remembering or thinking about the traumatic event. They may resist talking about what happened or how they feel about it.

Alterations in cognition and mood: Inability to remember important aspects of the traumatic event, negative thoughts and feelings leading to on going and distorted beliefs about oneself or others (e.g., “I am bad,” “No one can be trusted”); distorted thoughts about the cause or consequences of the event leading to wrongly blaming self or other; on going fear, horror, anger, guilt or shame; much less interest in activities previously enjoyed; feeling detached or estranged from others; or being unable to experience positive emotions (a void of happiness or satisfaction).

Alterations in arousal and reactivity: Arousal and reactive symptoms may include being irritable and having angry outbursts; behaving recklessly or in a self-destructive way; being overly watchful of one’s surroundings in a suspecting way; being easily startled; or having problems concentrating or sleeping.

Many people who are exposed to a traumatic event experience symptoms similar to those described above in the days following the event. For a person to be diagnosed with PTSD, however, symptoms must last for more than a month and must cause significant distress or problems in the individual’s daily functioning. 

Many individuals develop symptoms within three months of the trauma, but symptoms may appear later and often persist for months and sometimes years. PTSD often occurs with other related conditions, such as depression, anxiety as well as alcohol and substance misuse.

Treatment of PTSD

Any of the following treatment options may be recommended:

1. Watchful waiting – monitoring your symptoms to see whether they improve or get worse without treatment
2. antidepressants – such as SSRIs
3. psychological therapies – such as trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR)
4. Treatment of other concomitant mental illness as well as alcohol/substance misuse.

How does medical cannabis help?

People with PTSD

• Have lower levels of the neurotransmitter anandamide, an endocannabinoid that binds to CB1. (1)
• More CB1 receptors in brain regions associated with fear and anxiety than volunteers without PTSD
• “If anandamide levels are too low the brain compensates by increasing the number of CB1 receptors” (2)

CBD prevents the breakdown of anandamide, which binds to the CB1 receptors potentiating endocannabinoid signaling.

CBD can reduce anxiety through its actions on several receptors, which are known to regulate fear and anxiety-related behaviours. 1

THC binds to the CB1 receptor directly helps reduce sleep latency and REM sleep which results in less nightmares.

THC also modulates threat related processing in trauma-exposed individuals with PTSD (3).

Therefore medical cannabis can be effective in treating symptoms of PTSD and complex PTSD. 

As patients suffering from PTSD experience intrusive thoughts, flashbacks, sleep disruptions, and demonstrate avoidance behavior, these symptoms not only contribute to the persistence of PTSD, but also render treatment difficult. 

The prolonged stressors and symptom persistence cause derangement in the central neurobiological process, particularly in the prefrontal cortex, hippocampus, amygdala, and cingulate gyrus, which can lead to nightmares, sleep disruptions, and anxiety. 

Research is ongoing and medical cannabis has shown real promise in the treatment of PTSD. I have certainly observed this in my clinical practice. Where conventional treatment is unsuccessful, those who access medical cannabis may experience better quality of life, psychosocial functioning, and working ability with medical cannabis treatment alongside psychological therapies.

References

1. Elevated brain cannabinoid CB1 receptor availability in post-traumatic stress disorder: a positron emission tomography study. Molecular Psychiatry, 2013; DOI: 10.1038/mp.2013.61
2. (ScienceDaily. 2020. Brain-Imaging Study Links Cannabinoid Receptors To Post-Traumatic Stress Disorder: First Pharmaceutical Treatment For PTSD Within Reach. [online] Available at: <https://www.sciencedaily.com/releases/2013/05/130514085016.htm#:~:text=If%20anandamide%20levels%20are%20too,been%20shown%20to%20impair%20memory
3. Cannabinoid modulation of corticolimbic activation to threat in trauma-exposed adults: a preliminary study. Psychopharmacology (Berl)

. 2020 Jun;237(6):1813-1826. doi: 10.1007/s00213-020-05499-8. Epub 2020 Mar 11.