3,4-Methylenedioxymethamphetamine: MDMA.
Now you're probably heard of this compound
in the context of the recreational drug Ecstasy.
But today I want to talk about MDMA not
as a recreational drug but as a
potential new treatment in medicine.
And then very important treatment for
psychiatry because MDMA could offer us
in psychiatry for the first time the
opportunity to tackle trauma, and
psychological trauma particularly that
caused by child abuse and maltreatment
is at the heart of all or most
psychiatric disorders due to anxiety and
addictions. Psychiatry is in need of this
innovative approach, because current
treatments are failing patients.
Hi, my name's Ben Sessa. I'm a child and
adolescent psychiatrist. Now that means I
trained as a medical doctor then
specialized in mental health and then
specialized in child and adolescent
mental health. But for the last five
years I've been working with adults with
mental health disorders and addictions
due to misuse of drugs. And that
developmental pathway of my own from
working with child abuse into adults
with mental disorders and addictions has
brought me to the door of MDMA. And I'm
gonna propose today that MDMA could be
important for the future of psychiatry
as the discovery of antibiotics was
for general medicine a hundred years ago.
So when we think about child abuse we
think about physical abuse, mental abuse,
emotional abuse, sexual abuse and neglect.
And we think about noxious environments.
We think about parents with mental
disorder. We think about parents who are
addicted to drugs. And social issues like
poverty and poor housing, poor education.
Now I'm going to illustrate my talk
today with a patient and I'm going to
call her Claire.
Now Claire was no single particular
patient of mine. Rather she's an
amalgamation of many different people
I've met in the last 18 years working as
a medical doctor. She's certainly not the
worst.
Now what was Claire's environment like
she was growing up. Well, her mother was
depressed. Now unfortunately the family
doctor didn't have time to accurately
diagnose and treat depression, rather
Claire's mother was put onto one
antidepressant after another,
never really got therapy. Claire's mother
also had a lot of aches and pains
typical what we call psychosomatic
symptoms in depression, and as a result
the family doctor put her on to opiate
based painkillers which she promptly
became addicted to. Now Claire's father,
now he was alcoholic and he was often
not around in and out of prison. Which is
just as well because when he was there
he was physically abusive to Claire and
her mother. Okay so what does this kind
of chaotic, frightening environment do
to the developing child brain. I'm going
to give you a brief neurophysiology
lesson if I may. There's a part of the
brain called the amygdala. Now the
amygdala is a very ancient part of the
mammalian brain and many other animals
other than humans have an amygdala. The
amygdala lights up when stimulated by
fear in the environment, by a frightening
stimulus. It lights up and it says
fight-or-flight, get out!
Now there's another part of the brain
much more sophisticated part, called the
prefrontal cortex and it's right here at
the front above the eyes.
Now the prefrontal cortex only humans
have. And it's in the prefrontal cortex
where we use logic and reasoning to
rationalize the situation and we can use
our prefrontal cortex to overcome that
instinctive fear response from the
amygdala. Now when Claire was growing up
she never knew from one moment to the
next whether the adult coming into the
room, were they going to give her a kiss
or a cuddle or do a jigsaw with her, or
they're going to punch her or kick her
or burn her with their cigarette. Or were
they going to rape her. Because
throughout her childhood Claire was also
subjected to sexual abuse. Now there's a
group of disorders called the anxiety
disorders and one of the most important
is what we call post-traumatic stress
disorder or PTSD. Now PTSD, some of the
core features: very low mood, anxiety, high
levels of anxiety, what we call hyper
vigilance. This edginess this jumpiness,
exactly how claire felt throughout her
childhood and adolescence. Never knowing
whether they next assailant or assault
was around the corner. Another core
feature of PTSD what we call
re-experiencing phenomena. Flashbacks, in
which the patient has sudden
remembrances of these painful traumatic
memories. They can just pop into the head
at any time, triggered by some cue in the
environment. And when they have those
experiences those daytime flashbacks,
they relive the trauma in all the
sensory modalities and this results in
them freezing or dissociating to try and
block out the pain. Now Claire
experienced all of this as she was
growing up. High levels of self-harm and
suicide are associated with PTSD. Claire
would cut her thighs and her breasts.
Pretty common form of cutting in
children who've been sexually abused.
She was being sexually abused by clients of
her mother, because her mother had moved
on from the addiction to painkillers and
was using street heroin when Claire was
a teenager. And because of the way the
war on drugs has set up that reduces
access to treatment for people with
opiate dependence she had to pay for her
heroin using sex work and the clients
would sexually abuse Claire. Now it's
very hard to treat PTSD and it has a
high treatment resistance, 50% of people
do not respond to the traditional
treatments. How do we treat it? Well, we
can treat it with medications. We can
treat it with psychotherapies. And the
medications we use: there's a broad range
of drugs. No single drug, and this is very
important, no single drug cures PTSD.
Rather we treat the disorder
symptomatically: if the patient's
depressed give them an antidepressant. If
their mood fluctuates give them a mood
stabilizer. If they can't sleep
give them a hypnotic.
And if that edginess and that fear
spills over into paranoia and psychosis,
give the patient an anti-psychotic drug.
And they have to take these drugs day in
day out for weeks, months, decades. They
have to keep taking them because the
drugs we use to treat trauma when it's
due to this level of severity do not
attack the root cause of trauma. They
paper over the cracks. A good analogy
would be taking aspirin or ibuprofen
when you have a fever. Now a fever is
caused by an infection, by a
microorganism. Sure you can take paracetamol
or ibuprofen and this will lower
the temperature and make you feel a bit
better but it doesn't attack the root
cause. And that's what we do when we give
these patients these daily SSRI drugs. We
paper over the cracks. We maintain the
symptoms at a manageable level. We also
use psychotherapies to treat PTSD, and there's
again a broad range of these: DBT
CBT, EMDR, trauma focused psychotherapy,
CAT, APT... Now all of them have a pretty
similar approach which actually is an
old wives tales which is: a problem
shared is a problem halved. "Let's talk
about your trauma. Claire tell me about
your rape." Now that's fine for 50% of
patients but for a significant half they
just cannot do that. As soon as Claire is
asked to talk about her rape she freezes,
she flees, she drops out of treatment. Now
by the time she was 15 Claire had been
removed from the family home and she was
brought up in a succession of foster
placements and children's houses and
hostels where the abuse continued. And
she was self-harm cutting and she
started drinking and by the time she was
18 she was using heroin as well.
Sometimes working in psychiatry can feel
pretty desperate, can feel pretty
hopeless. Sometimes it feels as if
psychiatry is a palliative care
profession. And this is the truth because
the treatments we use do not get to the
root cause of the problem, the trauma.
They paper over the cracks. And I think
the pharma industry know this and they
queue up and they
provide us with product after product to
give to our patients that doesn't quite
cure them but it gets them slightly
better to function. And they have to keep
taking them. Indeed I would say that we
are in psychiatry today where we were in
general medicine 100 years ago. Now 100
years ago in general medicine, humanity
was losing the battle to the infectious
diseases. Oh we were very good at
classifying and diagnosing them. We knew
who got smallpox. We knew people died of
post-operative surgery. We knew there
were microorganisms but we didn't have a
treatment. And then at the beginning of
the 20th century we discovered the
antibiotics. Not symptomatic treatment
but treatment that goes to the core of
the cause and we started getting on top
of infectious disease. Now psychiatry
today is in a similar place. We're very
good at classifying and diagnosing. Our
epidemiology is superb. We write these
thick diagnostic manuals. We know who
gets depression. We know who gets anxiety.
We even know the cause: trauma, child
abuse, maltreatment, poor social
conditions. But our treatments are lousy.
And I'm quite shocked the way the empathy
switch and our understanding of these
patients seems to be switched off. We
have lots of gushing sentimentality for
the little five and six year old who's
being abused and we throw money at our
television sets on these campaigns to
improve the lives of these poor little
innocent victims. Well, let me tell you
what happens to that little five or six
year old when they're 11 or 12. On goes
the hood, start smoking weed. By the time
they're 16 they're buying and selling
amphetamine and by the time they're
Claire's age in their mid-20s, they're
addicted to heroin and alcohol. And
suddenly we have lost our empathy. These
people are public enemy number one. "It's
your fault Claire. You brought this upon
yourself. It's your lifestyle choice." And
I'm quite shocked and having worked in
pediatrics and seen the developmental
trajectory that is so inevitable from
early trauma into adolescent and then
adult mental health and addictions, we
have to hold on to that sense of
compassion and evidence-based
understanding
about the developmental trajectory there.
So it does sound desperate, but all is
not lost.
MDMA. MDMA has some fascinating qualities.
Indeed I would suggest that if you were
to invent a hypothetical drug to treat
trauma, it would be MDMA. The way it works
in terms of its receptors and its
subjective psychological effects ticks
all the right boxes. At one level of
receptors it causes a increased positive
mood. Lowering of depression, lowering of
anxiety. At another group of receptors it
speeds the patient up, mild stimulation
which motivates them to engage in
therapy. At another level it relaxes
the patient paradoxically at the same
time as the stimulation and this puts
the patient into the optimal arousal
zone where they can engage in
psychotherapy. But perhaps the most
important thing about MDMA and the most
important clinical tool is its ability
to provide a sense of empathy and
understanding and emotional security. It
can hold the patient in a place where
they can think about and access their
trauma like they've never been able to
do before. One of the ways in which MDMA
works is it increases the release of a
hormone called oxytocin. Now oxytocin is
released from the brains of
breastfeeding mothers. It's a hormone
that engenders a sense of attachment and
bonding. And that's what's happening in
the patient who takes MDMA. And also it
acts directly on the amygdala to reduce
that fear response whilst at the same
time boosting the prefrontal response,
allowing the patient to see things in a
new light. A positive light. So let's go
back to Claire. She's 40 now. She's been
in and out of psychiatric hospitals,
having tried to take her own life and
the inception. She's been on all the
antipsychotic and antidepressant mood
stabiliser drugs. She's tried all the
psychotherapies but she cannot engage
because she will not talk about her
feelings. So she comes into a course of
MDMA-assisted psychotherapy.
Wwhat does it look like? Well,
it's weekly sessions, maybe eight, ten,
twelve weeks long. The two therapists,
male-female pair. You do not take MDMA
everyday, you do not take it every
week. Over that course of 12 sessions
you'll take the MDMA three times and the
other sessions you talk about the
material that's released on the MDMA
session. So what does Claire actually
feel when she takes this MDMA? What she
feels is a sense of warmth and
understanding and a sense of containment
within that relationship she's having
with the therapist. MDMA is like it's
like a lifejacket like a bulletproof
vest to wear to go into battle with your
trauma. This is not ecstasy! She's not
enjoying some raver's euphoric ecstasy
delight. This is still trauma focused
psychotherapy and it is still hard and
distressing for her, but she can just
about do it with MDMA on board. So when
the therapist says: "Claire, tell me about
your rape". Now in the past just the word
rape and she'd be out the door, but on
MDMA she says: "yeah, I can talk about that!
I can see him now coming into the room. I
can smell the whiskey on his breath and
I can feel the stubble on his face as
he's raping me". And she talks about it
and she explores it and she reflects
upon it and she can begin the process of
healing. And from here she can start her
journey. She can attack the root cause of
her problems. Not just maintain the
symptoms at a level. So, does it work? Well
we've known about MDMA for very long
time and indeed we've used MDMA in
underground therapy for 30 or 40 years.
And there are thousands of positive
anecdotal cases. I get five emails a week
from all over the world: "Dr. Sessa, I've
had PTSD for years. I've tried everything
and now I tried MDMA and I'm starting to
make a breakthrough!"
Now, anecdotal reports like that are
interesting but they're not science so
we've done the science. And some
important studies in recent years.
Big study in the States
showed that a single course of MDMA
therapy, 16-week course, patient takes
MDMA three times tested against a
placebo. At the end of that course 85% of
the people no longer met the diagnostic
criteria for PTSD. Not just a relief of
symptoms, they didn't have PTSD!
Now that cohort were then followed up
three years later, the same no PTSD. Many
of those people had come off their daily
medications. They were cured! We don't use
the word "cure" in psychiatry. We've become
learned helplessness position of-- This is
the truth! If you're diagnosed with a
severe mental disorder like anxiety or
depression in your 20s and the
developmental route of that disorder is
severe child abuse, there's a pretty good
chance, and I'm sorry to say this, there's
a pretty good chance you will still be
going to psychiatric clinics in your 60s
and 70s. Now that is not good enough and
we're in this position because we're not
tackling trauma. So, it works but is it
safe? Well, when we talk about safety of
clinical MDMA, what we must not do is
look at the risks of recreational
ecstasy. I don't even know what ecstasy
is anymore!
Ecstasy is over here, what is ecstasy?
Some dodgy pill bought in some dodgy
club of some dodgy geezer, that may or
may not contain MDMA plus or minus
whatever far more toxic substance. And
indeed when you hear about the very
high-profile deaths of people who take
ecstasy, it invariably is not MDMA. So,
let's not look at ecstasy as a measure
of MDMA. Let's look at clinical MDMA. Now,
when you use clinical MDMA, you take
it under medical supervision. It is pure.
The MDMA that I'm using in my studies is
99.98% pure! Very expensive!
(laughter)
We do it under medical supervision with
a doctor and a nurse and a psychologist.
And under those conditions the risks are
reduced to a absolute minimum. Indeed
after 40 years of MDMA research, there
has not been a single serious adverse
drug reaction, not one! And certainly no
deaths. So, we need to do this research
and we need to do this research in an
evidence-based, compassionate way. Looking
at the data. We need to ignore the
socio-political agenda that says any
drug that's being used recreationally
must also be very bad and dangerous. That
sort of attitude hampers research. And we
need scientists to drive this. It works,
it's safe. And it offers patients like
Claire for the first time in their life
an opportunity to break through from
that trauma and not become a lifelong
chronic PTSD sufferer. So where were we
going with MDMA research? Well, we've had
some studies, we've got more coming here.
I'm doing a study in Cardiff with
neuroimaging in which we're going to
give patients with PTSD MDMA and placebo
and we're going to look at
that relationship between the
amygdala and the prefrontal cortex. We're
also doing a study here in Bristol
giving patients with alcohol use
disorder MDMA, because underlying the
root of this addiction is trauma. So this
is an exciting time. Now people say: "This
is controversial!" And indeed, I was
introduced as a controversial speaker.
I'm not controversial, I'm a very boring
conservative doctor. I like data.
I like evidence-based data that helps my
patients. I'll tell you what's
controversial! What's controversial is
that more people have died returning
from Afghanistan and Iraq because
they've committed suicide because of
their untreated PTSD then ever died in
the conflict out there. That is
controversial and that is unethical! So
this is a important time for science.
MDMA could be the antibiotic that
psychiatry has been waiting for. We owe
that population of patients who are
being failed,
we owe them this research! We owe this
Claire! Thank you.
(applause)