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(applause)

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3,4-Methylenedioxymethamphetamine: MDMA.

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Now you're probably heard of this compound
in the context of the recreational drug Ecstasy.

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But today I want to talk about MDMA not 
as a recreational drug,

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but as a potential new treatment in medicine.

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And then very important treatment 
for psychiatry because MDMA could offer us

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in psychiatry for the first time the
opportunity to tackle trauma.

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And psychological trauma particularly that
caused by child abuse and maltreatment

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is at the heart of all or most psychiatric
disorders due to anxiety and addictions.

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Psychiatry is in need of this 
innovative approach,

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because current treatments 
are failing patients.

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Hi, my name's Ben Sessa. I'm a child and
adolescent psychiatrist.

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Now that means I trained as a medical doctor,

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then specialized in mental health

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and then specialized in child 
and adolescent mental health.

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But for the last five years I've 
been working with adults with

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mental health disorders and addictions
due to misuse of drugs.

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And that developmental pathway 
of my own,

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from working with child abuse into adults

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with mental disorders and addictions has
brought me to the door of MDMA.

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And I'm gonna propose today 
that MDMA could be

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important for the future of psychiatry
as the discovery of antibiotics was

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for general medicine a hundred years ago.

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So when we think about child abuse we think
about physical abuse, mental abuse,

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emotional abuse, sexual abuse and neglect.

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And we think about noxious environments.

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We think about parents with mental disorder. 


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We think about parents
who are addicted to drugs.

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And social issues like poverty and poor housing, poor education.

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Now I'm going to illustrate my talk

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today with a patient and I'm going to

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call her Claire.

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Now Claire was no single particular

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patient of mine. Rather she's an

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amalgamation of many different people

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I've met in the last 18 years working as

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a medical doctor. She's certainly not the

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worst.

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Now what was Claire's environment like

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she was growing up. Well, her mother was

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depressed. Now unfortunately the family

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doctor didn't have time to accurately

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diagnose and treat depression, rather

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Claire's mother was put onto one

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antidepressant after another,

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never really got therapy. Claire's mother

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also had a lot of aches and pains

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typical what we call psychosomatic

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symptoms in depression, and as a result

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the family doctor put her on to opiate

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based painkillers which she promptly

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became addicted to. Now Claire's father,

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now he was alcoholic and he was often

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not around in and out of prison. Which is

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just as well because when he was there

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he was physically abusive to Claire and

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her mother. Okay so what does this kind

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of chaotic, frightening environment do

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to the developing child brain. I'm going

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to give you a brief neurophysiology

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lesson if I may. There's a part of the

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brain called the amygdala. Now the

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amygdala is a very ancient part of the

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mammalian brain and many other animals

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other than humans have an amygdala. The

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amygdala lights up when stimulated by

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fear in the environment, by a frightening

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stimulus. It lights up and it says

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fight-or-flight, get out!

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Now there's another part of the brain

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much more sophisticated part, called the

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prefrontal cortex and it's right here at

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the front above the eyes.

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Now the prefrontal cortex only humans

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have. And it's in the prefrontal cortex

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where we use logic and reasoning to

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rationalize the situation and we can use

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our prefrontal cortex to overcome that

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instinctive fear response from the

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amygdala. Now when Claire was growing up

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she never knew from one moment to the

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next whether the adult coming into the

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room, were they going to give her a kiss

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or a cuddle or do a jigsaw with her, or

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they're going to punch her or kick her

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or burn her with their cigarette. Or were

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they going to rape her. Because

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throughout her childhood Claire was also

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subjected to sexual abuse. Now there's a

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group of disorders called the anxiety

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disorders and one of the most important

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is what we call post-traumatic stress

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disorder or PTSD. Now PTSD, some of the

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core features: very low mood, anxiety, high

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levels of anxiety, what we call hyper

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vigilance. This edginess this jumpiness,

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exactly how claire felt throughout her

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childhood and adolescence. Never knowing

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whether they next assailant or assault

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was around the corner. Another core

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feature of PTSD what we call

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re-experiencing phenomena. Flashbacks, in

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which the patient has sudden

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remembrances of these painful traumatic

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memories. They can just pop into the head

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at any time, triggered by some cue in the

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environment. And when they have those

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experiences those daytime flashbacks,

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they relive the trauma in all the

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sensory modalities and this results in

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them freezing or dissociating to try and

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block out the pain. Now Claire

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experienced all of this as she was

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growing up. High levels of self-harm and

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suicide are associated with PTSD. Claire

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would cut her thighs and her breasts.

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Pretty common form of cutting in

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children who've been sexually abused.

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She was being sexually abused by clients of

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her mother, because her mother had moved

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on from the addiction to painkillers and

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was using street heroin when Claire was

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a teenager. And because of the way the

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war on drugs has set up that reduces

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access to treatment for people with

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opiate dependence she had to pay for her

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heroin using sex work and the clients

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would sexually abuse Claire. Now it's

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very hard to treat PTSD and it has a

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high treatment resistance, 50% of people

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do not respond to the traditional

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treatments. How do we treat it? Well, we

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can treat it with medications. We can

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treat it with psychotherapies. And the

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medications we use: there's a broad range

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of drugs. No single drug, and this is very

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important, no single drug cures PTSD.

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Rather we treat the disorder

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symptomatically: if the patient's

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depressed give them an antidepressant. If

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their mood fluctuates give them a mood

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stabilizer. If they can't sleep

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give them a hypnotic.

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And if that edginess and that fear

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spills over into paranoia and psychosis,

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give the patient an anti-psychotic drug.

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And they have to take these drugs day in

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day out for weeks, months, decades. They

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have to keep taking them because the

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drugs we use to treat trauma when it's

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due to this level of severity do not

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attack the root cause of trauma. They

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paper over the cracks. A good analogy

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would be taking aspirin or ibuprofen

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when you have a fever. Now a fever is

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caused by an infection, by a

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microorganism. Sure you can take paracetamol

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or ibuprofen and this will lower

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the temperature and make you feel a bit

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better but it doesn't attack the root

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cause. And that's what we do when we give

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these patients these daily SSRI drugs. We

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paper over the cracks. We maintain the

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symptoms at a manageable level. We also

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use psychotherapies to treat PTSD, and there's

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again a broad range of these: DBT

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CBT, EMDR, trauma focused psychotherapy,

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CAT, APT... Now all of them have a pretty

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similar approach which actually is an

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old wives tales which is: a problem

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shared is a problem halved. "Let's talk

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about your trauma. Claire tell me about

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your rape." Now that's fine for 50% of

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patients but for a significant half they

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just cannot do that. As soon as Claire is

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asked to talk about her rape she freezes,

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she flees, she drops out of treatment. Now

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by the time she was 15 Claire had been

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removed from the family home and she was

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brought up in a succession of foster

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placements and children's houses and

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hostels where the abuse continued. And

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she was self-harm cutting and she

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started drinking and by the time she was

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18 she was using heroin as well.

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Sometimes working in psychiatry can feel

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pretty desperate, can feel pretty

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hopeless. Sometimes it feels as if

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psychiatry is a palliative care

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profession. And this is the truth because

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the treatments we use do not get to the

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root cause of the problem, the trauma.

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They paper over the cracks. And I think

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the pharma industry know this and they

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queue up and they

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provide us with product after product to

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give to our patients that doesn't quite

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cure them but it gets them slightly

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better to function. And they have to keep

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taking them. Indeed I would say that we

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are in psychiatry today where we were in

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general medicine 100 years ago. Now 100

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years ago in general medicine, humanity

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was losing the battle to the infectious

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diseases. Oh we were very good at

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classifying and diagnosing them. We knew

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who got smallpox. We knew people died of

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post-operative surgery. We knew there

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were microorganisms but we didn't have a

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treatment. And then at the beginning of

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the 20th century we discovered the

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antibiotics. Not symptomatic treatment

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but treatment that goes to the core of

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the cause and we started getting on top

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of infectious disease. Now psychiatry

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today is in a similar place. We're very

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good at classifying and diagnosing. Our

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epidemiology is superb. We write these

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thick diagnostic manuals. We know who

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gets depression. We know who gets anxiety.

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We even know the cause: trauma, child

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abuse, maltreatment, poor social

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conditions. But our treatments are lousy.

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And I'm quite shocked the way the empathy

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switch and our understanding of these

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patients seems to be switched off. We

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have lots of gushing sentimentality for

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the little five and six year old who's

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being abused and we throw money at our

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television sets on these campaigns to

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improve the lives of these poor little

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innocent victims. Well, let me tell you

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what happens to that little five or six

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year old when they're 11 or 12. On goes

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the hood, start smoking weed. By the time

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they're 16 they're buying and selling

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amphetamine and by the time they're

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Claire's age in their mid-20s, they're

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addicted to heroin and alcohol. And

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suddenly we have lost our empathy. These

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people are public enemy number one. "It's

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your fault Claire. You brought this upon

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yourself. It's your lifestyle choice." And

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I'm quite shocked and having worked in

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pediatrics and seen the developmental

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trajectory that is so inevitable from

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early trauma into adolescent and then

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adult mental health and addictions, we

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have to hold on to that sense of

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compassion and evidence-based

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understanding

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about the developmental trajectory there.

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So it does sound desperate, but all is

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not lost.

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MDMA. MDMA has some fascinating qualities.

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Indeed I would suggest that if you were

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to invent a hypothetical drug to treat

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trauma, it would be MDMA. The way it works

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in terms of its receptors and its

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subjective psychological effects ticks

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all the right boxes. At one level of

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receptors it causes a increased positive

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mood. Lowering of depression, lowering of

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anxiety. At another group of receptors it

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speeds the patient up, mild stimulation

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which motivates them to engage in

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therapy. At another level it relaxes

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the patient paradoxically at the same

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time as the stimulation and this puts

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the patient into the optimal arousal

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zone where they can engage in

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psychotherapy. But perhaps the most

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important thing about MDMA and the most

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important clinical tool is its ability

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to provide a sense of empathy and

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understanding and emotional security. It

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can hold the patient in a place where

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they can think about and access their

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trauma like they've never been able to

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do before. One of the ways in which MDMA

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works is it increases the release of a

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hormone called oxytocin. Now oxytocin is

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released from the brains of

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breastfeeding mothers. It's a hormone

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that engenders a sense of attachment and

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bonding. And that's what's happening in

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the patient who takes MDMA. And also it

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acts directly on the amygdala to reduce

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that fear response whilst at the same

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time boosting the prefrontal response,

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allowing the patient to see things in a

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new light. A positive light. So let's go

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back to Claire. She's 40 now. She's been

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in and out of psychiatric hospitals,

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having tried to take her own life and

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the inception. She's been on all the

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antipsychotic and antidepressant mood

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stabiliser drugs. She's tried all the

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psychotherapies but she cannot engage

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because she will not talk about her

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feelings. So she comes into a course of

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MDMA-assisted psychotherapy.

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Wwhat does it look like? Well,

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it's weekly sessions, maybe eight, ten,

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twelve weeks long. The two therapists,

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male-female pair. You do not take MDMA

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everyday, you do not take it every

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week. Over that course of 12 sessions

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you'll take the MDMA three times and the

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other sessions you talk about the

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material that's released on the MDMA

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session. So what does Claire actually

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feel when she takes this MDMA? What she

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feels is a sense of warmth and

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understanding and a sense of containment

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within that relationship she's having

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with the therapist. MDMA is like it's

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like a lifejacket like a bulletproof

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vest to wear to go into battle with your

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trauma. This is not ecstasy! She's not

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enjoying some raver's euphoric ecstasy

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delight. This is still trauma focused

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psychotherapy and it is still hard and

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distressing for her, but she can just

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about do it with MDMA on board. So when

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the therapist says: "Claire, tell me about

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your rape". Now in the past just the word

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rape and she'd be out the door, but on

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MDMA she says: "yeah, I can talk about that!

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I can see him now coming into the room. I

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can smell the whiskey on his breath and

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I can feel the stubble on his face as

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he's raping me". And she talks about it

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and she explores it and she reflects

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upon it and she can begin the process of

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healing. And from here she can start her

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journey. She can attack the root cause of

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her problems. Not just maintain the

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symptoms at a level. So, does it work? Well

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we've known about MDMA for very long

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time and indeed we've used MDMA in

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underground therapy for 30 or 40 years.

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And there are thousands of positive

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anecdotal cases. I get five emails a week

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from all over the world: "Dr. Sessa, I've

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had PTSD for years. I've tried everything

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and now I tried MDMA and I'm starting to

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make a breakthrough!"

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Now, anecdotal reports like that are

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interesting but they're not science so

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we've done the science. And some

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important studies in recent years.

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Big study in the States

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showed that a single course of MDMA

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therapy, 16-week course, patient takes

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MDMA three times tested against a

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placebo. At the end of that course 85% of

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the people no longer met the diagnostic

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criteria for PTSD. Not just a relief of

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symptoms, they didn't have PTSD!

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Now that cohort were then followed up

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three years later, the same no PTSD. Many

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of those people had come off their daily

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medications. They were cured! We don't use

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the word "cure" in psychiatry. We've become

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learned helplessness position of-- This is

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the truth! If you're diagnosed with a

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severe mental disorder like anxiety or

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depression in your 20s and the

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developmental route of that disorder is

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severe child abuse, there's a pretty good

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chance, and I'm sorry to say this, there's

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a pretty good chance you will still be

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going to psychiatric clinics in your 60s

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and 70s. Now that is not good enough and

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we're in this position because we're not

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tackling trauma. So, it works but is it

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safe? Well, when we talk about safety of

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clinical MDMA, what we must not do is

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look at the risks of recreational

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ecstasy. I don't even know what ecstasy

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is anymore!

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Ecstasy is over here, what is ecstasy?

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Some dodgy pill bought in some dodgy

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club of some dodgy geezer, that may or

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may not contain MDMA plus or minus

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whatever far more toxic substance. And

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indeed when you hear about the very

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00:17:03,040 --> 00:17:10,359
high-profile deaths of people who take

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ecstasy, it invariably is not MDMA. So,

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let's not look at ecstasy as a measure

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of MDMA. Let's look at clinical MDMA. Now,

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when you use clinical MDMA, you take

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it under medical supervision. It is pure.

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The MDMA that I'm using in my studies is

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99.98% pure! Very expensive! 
(laughter)

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We do it under medical supervision with

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a doctor and a nurse and a psychologist.

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And under those conditions the risks are

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reduced to a absolute minimum. Indeed

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after 40 years of MDMA research, there

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00:17:42,990 --> 00:17:48,630
has not been a single serious adverse

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drug reaction, not one! And certainly no

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deaths. So, we need to do this research

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and we need to do this research in an

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evidence-based, compassionate way. Looking

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at the data. We need to ignore the

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socio-political agenda that says any

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drug that's being used recreationally

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must also be very bad and dangerous. That

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sort of attitude hampers research. And we

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need scientists to drive this. It works,

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00:18:19,320 --> 00:18:23,760
it's safe. And it offers patients like

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Claire for the first time in their life

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00:18:23,760 --> 00:18:27,840
an opportunity to break through from

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that trauma and not become a lifelong

417
00:18:27,840 --> 00:18:33,179
chronic PTSD sufferer. So where were we

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00:18:31,110 --> 00:18:35,190
going with MDMA research? Well, we've had

419
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some studies, we've got more coming here.

420
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I'm doing a study in Cardiff with

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neuroimaging in which we're going to

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00:18:38,669 --> 00:18:43,320
give patients with PTSD MDMA and placebo

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and we're going to look at

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that relationship between the

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amygdala and the prefrontal cortex. We're

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00:18:47,730 --> 00:18:51,419
also doing a study here in Bristol

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00:18:49,159 --> 00:18:54,840
giving patients with alcohol use

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disorder MDMA, because underlying the

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00:18:54,840 --> 00:19:00,809
root of this addiction is trauma. So this

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00:18:58,230 --> 00:19:02,460
is an exciting time. Now people say: "This

431
00:19:00,809 --> 00:19:04,320
is controversial!" And indeed, I was

432
00:19:02,460 --> 00:19:06,270
introduced as a controversial speaker.

433
00:19:04,320 --> 00:19:08,880
I'm not controversial, I'm a very boring

434
00:19:06,270 --> 00:19:11,880
conservative doctor. I like data.

435
00:19:08,880 --> 00:19:14,429
I like evidence-based data that helps my

436
00:19:11,880 --> 00:19:16,860
patients. I'll tell you what's

437
00:19:14,429 --> 00:19:19,110
controversial! What's controversial is

438
00:19:16,860 --> 00:19:21,179
that more people have died returning

439
00:19:19,110 --> 00:19:22,590
from Afghanistan and Iraq because

440
00:19:21,179 --> 00:19:25,500
they've committed suicide because of

441
00:19:22,590 --> 00:19:27,510
their untreated PTSD then ever died in

442
00:19:25,500 --> 00:19:32,760
the conflict out there. That is

443
00:19:27,510 --> 00:19:35,150
controversial and that is unethical! So

444
00:19:32,760 --> 00:19:38,340
this is a important time for science.

445
00:19:35,150 --> 00:19:40,620
MDMA could be the antibiotic that

446
00:19:38,340 --> 00:19:42,419
psychiatry has been waiting for. We owe

447
00:19:40,620 --> 00:19:43,630
that population of patients who are

448
00:19:42,419 --> 00:19:46,690
being failed,

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00:19:43,630 --> 00:19:50,220
we owe them this research! We owe this

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Claire! Thank you.
(applause)