Welcome to the world wide web page of Tod H. Mikuriya, M.D.
Cannabis Eases Post Traumatic Stress
By Tod Mikuriya, MD
Originally published in O'Shaughnessy's, Spring 2006
William Woodward, MD, of the American Medical Association, testifying before
Congress in 1937 against the Prohibition of cannabis, paraphrased a French
author (F. Pascal, 1934) to the effect that “Indian hemp has remarkable
properties in revealing the subconscious.” A Congressman asked, “Are
there any substitutes for that latter psychological use?” Woodward replied, “I
know of none. That use, by the way, was recognized by John Stuart Mill in his
work on psychology, where he referred to the ability of Cannabis or Indian
hemp to revive old memories —and psychoanalysis depends on revivivification
of hidden memories.”
For including that reference to Mill (1867) in the list I have been compiling
of conditions amenable to treatment by cannabis, I was ridiculed by Drug Czar
Barry McCaffrey in 1996. I stand by its inclusion, of course, and in the 10
years since California physicians have been approving cannabis use by patients,
I have found myself appreciating and confirming Mill’s insight with every
report that cannabis has eased symptoms of post-traumatic stress disorder.
PTSD As a Dissociative Disorder
PTSD—a chronic condition involving horrific memories that cannot be erased—is
a dissociative identity disorder. The victims’s psyche is fragmented
in response to contradictory inputs that cannot be resolved.
Dissociative identity disorders are expressed in bizarre or inappropriate behaviors
with intense sadness, fear, and anger. Repression or “forgetting” of
the experiences may develop as a coping mechanism.
When traumatic or abusive experiences cannot be integrated into normal consciousness —as
in the case of the Jekyl-Hyde behaviors of abusive parents or caregivers— creation
of separate personalities or identities may occur.
For example, the woman who was molested by a family member may have both superfically-compliant
and repressed-raging identities. The persona that’s presented to the
world can be swept away when a stimulus calls forth the overwhelming rage.
Such fragmenting of the individual personality causes tremendous stress. The
psyche is incomplete because of repression and denial. The person tries to
appear normal and logical but in fact is in turmoil, angry and depressed. The
inability to deal directly with emotional issues results in ongoing splitting
and compartmentalization of the personality —and in extreme cases, multiple
personalities, hysterical fugue (a separate state of consciousness that the
individual may not recall), blindness, paralysis, and other functional disruptions.
In 1994 the term “Multiple Personality Disorder” was replaced with
the more widely applicable “Dissociative Identity Disorder.” As
an article (by Foote et al) and editorial (Spiegel) in the April 2006 American
Journal of Psychiatry attest, it is only relatively recently that PTSD has
been characterized as a dissociative disorder.
Practical Treatment Goals
In treating PTSD, psychotherapy should focus on improving how the patient deals
with resurgent symptoms rather than revisitation of the events. Decreasing
vulnerability to symptoms and restoring control to the individual take priority
over insight as treatment goals. Revisiting the traumatic events without
closure and support is not useful but prolongs and exacerbates pain and fear
of loss of control. To repeat: cathartic revisiting of the traumatic experience(s)
without support and closure is anti-therapeutic and can exacerbate symptoms.
Physical pain, fatigue, and sleep deficit are symptoms that can be ameliorated.
Restorative exercise and diet are requisite components of treatment of PTSD
and depression. Cannabis does not leave the patient too immobile to exercise,
as do some analgesics, sedatives biodi-azapenes, etc. Regular aerobic exercise
(where injury does not interfere) relieves tension and restores control through
kinesthetic involvement. Exercise also internalizes the locus of control and
diminishes drug-seeking to manage emotional response.
The importance of sound sleep
PTSD often involves irritability and inability to concentrate, which is aggravated
by sleep deficit. Cannabis use enhances the quality of sleep through modulation
of emotional reactivity. It eases the triggered flashbacks and accompanying
emotional reactions, including nightmares.
The importance of restoring circadian rhythm of sleep cannot be overestimated
in the management of PTSD. Avoidance of alcohol is important in large part
because of the adverse effects on sleep. The short-lived relaxation and relief
provided by alcohol are replaced by withdrawal symptoms at night, causing anxiety
and the worsening of musculoskeletal pain.
Evening oral cannabis may be a useful substitute for alcohol. With proper dosage,
the quality and length of sleep can be improved without morning dullness or
hangover. For naïve patients, use of oral cannabis should be gradually
titrated upward in a supportive setting; this is the key to avoiding unwanted
mental side effects.
I recommend the protocol J. Russell Reynolds M.D., commended to Queen Victoria: “The
dose should be given in minimum quantity, repeated in not less than four to
six hours, and gradually increased by one drop every third or fourth day, until
either relief is obtained, or the drug is proved, in such case to be useless.
With these precautions I have never met with any toxic effects, and have rarely
failed to find, after a comparatively short time, either the value or the uselessness
of the drug.”
The advantage of oral over inhaled cannabis for sleep is duration of effect;
a disadvantage is the time of onset (45-60 minutes). When there is severe recurrent
insomnia with frequent awakening it is possible to medicate with inhaled cannabis
and return to sleep. An unfortunate result of cannabis prohibition is that
researchers and plant breeders have not been able to develop strains in which
sedative components of the plant predominate.
Modulation, Not Extinction
Although it is now widely accepted that cannabinoids help extinguish painful
memories, my clinical experience suggests that “extinguish” is
a misnomer.
Cannabis modulates emotional reactivity, enabling people to integrate painful
memories —to look at them and begin to deal with them, instead of suppressing
them until a stimulus calls them forth with overwhelming force.
The modulation of emotional response relieves the flooding of negative affect.
The skeletal and smooth muscle relaxation decreases the release of corticosteroids
and escalating “fight-or-flight” agitation. The modulation of mood
prevents or significantly decreases the symptoms of anxiety attacks, mood swings,
and insomnia.
While decreasing the intensity of affectual response, cannabis increases introspection
as evidenced by the slowing of the EEG after initial stimulation. Unique anti-depressive
effects are experienced immediately with an alteration in cognition. Obsessive
and pressured thinking give way to introspective free associations (given relaxed
circumstances). Emotional reactivity is calmed, worries become less pressing.
Used on a continuing basis, cannabis can hold depressive symptoms at bay. Agitated
depression appears to respond to the anxiolytic component of the drug. Social
withdrawal and emotional shutting down are reversed.
The short-term memory loss induced by cannabis that may be undesirable in other
contexts is therapeutic in controlling obsessive ideation, amplified anxiety
and fear of loss of control ignited by the triggering stimuli.
Easement Effects of Cannabis
In treating PTSD, cannabis provides control and amelioration of chronic stressors
without adverse side effects. Mainstream medicine treats PTSD symptoms such
as hyperalertness, insomnia, and nightmares with an array of SSRI and tricyclic
anti-depressants, sedatives, analgesics, muscle relaxants, etc., all of which
provide inadequate relief and have side effects that soon become problematic.
Sedatives, both prescribed and over-the-counter, when used chronically, commonly
cause hangovers, dullness, sedation, constipation, weight gain, and depression.
See chart at right.
Cannabis is a unique psychotropic immunomodulator which can best be categorized
as an “easement.” Modulating the overwhelming flood of negative
affect in PTSD is analogous to the release of specific tension, a process of “unclenching” or
release. As when a physical spasm is relieved, there is a perception of “wholeness” or
integration of the afflicted system with the self. For some, this perceptual
perspective is changed in other ways such as distancing (separating the reaction
from the stimulus, which can involve either lessening the reaction, as with
modulation, or repressing/suppressing the memory; walling it off; forgetting).
The modulation of emotional response relieves the flooding of negative affect.
The skeletal and smooth muscle relaxation decreases the sympathetic nervous
reactivity and kindling component of agitation. Fight/flight responses and
anger symptoms are significantly ameliorated. The fear of loss of control diminishes
as episodes of agitation and feeling overwhelmed are lessened. Experiences
of control then come to prevail. Thinking is freed from attachment to the past
and permitted to fix on the present and future. Instead of being transfixed
by nightmares, the sufferer is freed to realize dreams.
Based on both safety and efficacy, cannabis should be considered first in the treatment of post-traumatic stress disorder. As part of a restorative program with exercise, diet, and psychotherapy, it should be substituted for “mainstream” anti-depressants, sedatives, muscle relaxants, tricyclics, etc.
Case Report:
A 55-year-old disabled male veteran had been a naval air crewman on patrol
during the Vietnam war. A P2V turbo-prop engine failed to reverse properly
on landing. A propeller broke loose, pierced the fuselage, and instantly
killed his crew mate who was two feet away. He brought a large binder of
documentation of the incident.
His PTSD was expressed primarily through a haunting, recurrent flashback nightmares
that replayed the traumatic event. Attendant were the feelings of being emotionally
overwhelmed. Sleep deficit was a salient aggravating factor for increasing
vulnerability. Cannabis restored sleep and controlled nightmares. Depression
and irritability had been eased.