(applause)
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
when 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 were they 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
the next assailant or assault
was around the corner.
Another core feature of PTSD,
what we call re-experiencing phenomena.
Flashbacks, when the patient has sudden
remembrances of 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.
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 her mother's clients,
because her mother had moved on
from the addiction to painkillers and
was using street heroin
when Claire was a teenager.
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.
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?
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.
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.
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.
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.
I would say that we're in psychiatry today where
we were in general medicine 100 years ago.
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.
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)