Is MDMA psychiatry’s antibiotic? | Ben Sessa | TEDxUniversityofBristol

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)