Is CBD a new “way out” from PTSD?
What doesn't kill us makes us stronger: Is that always so?
Most of the changes that happen in our life help us to survive, no matter what conditions we have experienced. A person knows how to adapt to various circumstances; with the change in our lives, we are changing. However, some events, especially which happened in early childhood or connected to violence, death, or intense fear, can cause a severe mental disorder, known as "Post-Traumatic Syndrome" (PTSD).
According to the National Mental Illness Alliance, PTSD affects approximately 3.5 percent of U.S. adults, which is around 8 million citizens. The National Center for PTSD estimated that about 7 or 8 people out of every 100 would potentially experience PTSD at some point in their lives. Well, this statistics doesn't look so bright.
Research suggests that women are twice more likely to be affected by PTSD than men. The ratio is approximately 10:4, according to the National PTSD Center. Traumatic events that are the most often cause of PTSD in men are rape, participation in hostilities, abandonment, and ill-treatment in childhood. The most traumatic events in women are rape, sexual abuse, physical assault, and childhood abuse, which unfortunately are more likely to happen throughout life.
It might be interesting to know that PTSD had been known for many years before it became a "trendy disorder." It had many names in the past - "shell shock" during the years of World War I and "combat fatigue" in the time of World War II. Despite the origin, PTSD does not just happen to veterans or war victims. It could and still can occur in people of any ethnicity, nationality or culture, and age.
Surfing the net, you go through the horrifying comments of people who were once victims of this psychological disorder. Affected people paid attention to the fact that thoughts or memories of a traumatic event break into their thoughts, affect concentration during the day, and appear like dreams at night. Dreams of this kind are, as a rule, of two types: the first, with the accuracy of a video recording, transmit a traumatic event as imprinted in the memory of a person who survived it; in dreams of the second type, the setting and characters can be completely different, but at least some of the elements (face, situation, sensation) are similar to those that occurred in the traumatic event. A man awakens from such a dream completely broken; his muscles are tense; he is sweating.
It seems like the fear never goes away, like a psychopathological respawn. Waking dreams are also possible, and they can seem so real that a person can feel as if he is experiencing the same traumatic experience again. Here is what some of the affected people say:
"Now I normally communicate with people, but sometimes I go "into injury." It seems to me that now they will attack me, even when I'm alone at home. I see pictures of how my father swings or chases after me, and I'm 6 or 8 years old, then I clog under the table and automatically shrink into the fetal position. I try to "save my life" even if nothing threatens me, and I can attack my friends because I suddenly see enemies in them. On the street, I always look around because it still seems to me that someone stalks me". ( Inna, 31)
"I still have a dream that my daughter is completely covered in blood and does not move," says Amina. She is forty-four years old, her daughter is fine. Fifteen years ago, Amina's niece, the daughter of her cousin, was shell-shocked and received many injuries. Until the evening of September 4, the family did not know whether the girl was alive or not until Amina found her in one of the Beslan hospitals. She says that their family didn't experience anything worse than on that day". (Amina, 44)
"My PTSD is from surviving a tornado. Sometimes, when my mind wanders too much, I think I hear the crashing of the lightning, and I'll cry. Sometimes I'll hold my hands over my ears to try to get the sound to stop. If the power goes out at all, I will ball up wherever I am and start expecting the worst to happen. I'm always scared that the building I'm in is going to be destroyed, so I try to shield myself the best I can, and I always feel so embarrassed. I feel like I'm irrational." (Maia Y., 28)
What seems confusing about PTSD is that it is not so important how severe the events were from the side of another person. Even though there are attempts to classify or narrow down the set of circumstances that would be considered genuinely traumatic, for some people, the cause of the injury is not so much the objective danger of the event as its subjective significance. For example, there are situations when people react sharply to what seems completely harmless. It happens, as a rule, because people believe that life in the form in which they knew it is over; something deeply tragic and destructive happened to them, and it is perceived by them that way, even if for others everything looks different.
In 2013 the American Psychiatric Association revised diagnostic criteria of PTSD. The fifth edition of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5) included several approaches to distinguish PTSD:
- Stress trigger
The person was directly exposed to or threatened by the death of himself or close people, sexual violence, bullying. Such a traumatic event could activate the primary mechanism of PTSD, which is fear, in the following ways:
- Direct exposure
- Traumatic event witnessing
- Occlusion/ interception
The traumatic event is persistently re-experienced and re-played in the following way(s):
- Emotional distress
- Physical reactivity after exposure to traumatic reminders
- Unwanted memories
- Avoidance of trauma-related stimuli
- Trauma-related inner thoughts or feelings
- Trauma-related external reminders
- Negative alterations in mood and behavior
- Partial amnesia or inability to recall key moments of the event
- Overly negative assumptions about the world
- Exaggerated blame
- Feeling of guilt
- Negative affect
- Decreased interest in activities
- Feeling isolated
- Difficulty experiencing positive affect
- Arousal and reactivity changes
- Irritability or aggression
- Risky or destructive behavior
- Heightened startle reaction
- Difficulty concentrating
- Difficulty sleeping
- Duration period
PTSD symptoms, or at least 3-4 of them, have to last for more than one month to be considered as follows. PTSD can be either acute or chronic. In those with severe PTSD, symptoms last for at least one month but less than three months after the traumatic event. In chronic PTSD, symptoms last for more than three months after exposure to trauma.
How your brain reacts to fear
By studying various parts of the brain that are responsible for fear and stress can also help to examine the causes of PTSD. One of these brain parts is a cerebellar tonsil, which is responsible for emotions, assimilation of knowledge, and memory. It turned out that it plays an active role in the emergence of fear (or, in other words, "teaches" to be afraid of something, for example, touching a hot stove), as well as in the early stages of extinguishing fear (or in other words, "teaches" not to be afraid).
Keeping faded memories and weakening the initial fear response is associated with the prefrontal cortex (PFC) of the brain, which is responsible for decision making, problem-solving, and environmental assessment. Each PFC zone has its role. For example, when PFC believes that the source of stress is under control, the medial prefrontal zone of PFC suppresses the anxiety center deep in the brainstem and controls the response to stress. Ventromedial PFC helps to maintain long-term fading of scary memories, and its size can affect its function.
"Talking cure" for PTSD
The most common types of PTSD treatment are either psychotherapy or psychological counseling; on the other hand, the use of specific drugs. However, in some cases, a combination of these two can be used to achieve the best result. Today, no one else forces people who are upset and preoccupied with trauma to tell a traumatic story again and again immediately after a traumatic experience. Previously, however, this was practiced: the "traumatic debriefing" technique was applied, since, as believed, it was possible to make people tell their story, then the latter would feel better. But later, it was discovered that insisting too much and pushing to say a story, as a rule, only reinforced memories and adverse reactions to trauma.
There are several effective techniques, and among them, the most reliable and practiced are:
- Progressive exposure therapy
- Correction of cognitive processing therapy
- Desensitization of the eye (eye movement desensitization)
These therapies have a lot in common: they all start by teaching people to relax because, for these therapies to be effective, you need to be able to relax and be relaxed when working with trauma. Even though treatment is very useful in particular cases, let's not be deceived by the possibility of a short-lived effect of psychological therapies.
How antidepressants work
Sertraline (Zoloft, Pfizer) and Paroxetine (Paxil, GlaxoSmithKline) are both FDA approved antidepressants for treatment in the United States. They are selective serotonin reuptake inhibitors (SSRIs) and have a similar mechanism of action. These drugs help to increase the level of serotonin, a brain neurotransmitter, which is often called the 'happy chemical.' Serotonin gives you a feeling of happiness, well-being, and good quality sleep. Although SSRIs are associated with approximately 60% of the overall response rate in patients with PTSD, only 20% to 30% of patients achieve complete remission.
There are also many other related drugs with relatively proven efficacy: serotonin and norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors, tricyclic antidepressant drugs, and partial 5-hydroxytryptamine (5-HT)1A receptor agonists. Venlafaxine (Effexor XR, Pfizer) is a commonly used drug of SNRIs type for the treatment of PTSD and some earlier generations of antidepressants, such as Desipramine, Amitriptyline, Imipramine (monoamine oxidase inhibitors). Studies by Davidson J.,2006 show that Venlafaxine had a response rate of 78%, and the remission rate was 40% in patients with PTSD. It was also approved for patients with major depressive disorder, generalized anxiety disorder, social anxiety disorder, and panic disorder.
Some medicines used in clinical practice do not have enough theoretical justification for use. These include second-generation antipsychotics, benzodiazepines, such as Valium, anticonvulsants such as Lamotrignin, and the typical antidepressant Trazodone, which is often prescribed as sleeping pills. Such drugs act primarily on the dopaminergic and serotonergic systems. They are used to relieve anxiety, irritability, and usually help patients to control their emotions better and to normalize sleep. Such atypical antipsychotics are associated with limited response and permanent symptoms, particularly in PTSD. Adverse effects may also limit tolerability and adherence. Clinical studies indicated that benzodiazepines are useful in managing only acute psychotic PTSD symptoms such as hallucinations and hyperarousal.
Among veterans with PTSD, as diagnosed by the Department of Veterans Affairs, 89% are treated with SSRIs. Reductions in PTSD scores in clinical trials of SSRIs have been similar to those observed in studies of psychotherapy for PTSD. Regardless of the treatment modality used, a high percentage of veterans who begin PTSD treatment eventually drop out. Friedman MJ.,2006 estimated that no more than 20% of veterans with PTSD are effectively treated, possibly because SSRIs are more effective in women than in men and because they are more effective in acute PTSD than in chronic disease.
In general, medications and psychotherapy are equally valid. However, The APA guidelines note that there are no psychotropic medications explicitly developed for PTSD treatment, drugs have been used in doses similar to those recommended or approved for other psychiatric illnesses, both in clinical practice and in pharmacotherapy research.
A significant burden of anxiety-related disorders and the limitations of current treatments place a high priority on developing novel pharmaceutical treatments.
Pros and cons of current PTSD treatment
Although clinically, antidepressants are not addictive like some drugs and alcohol, they can give people withdrawal symptoms when they stop taking them. Despite their efficacy in relieving some of the anxiety syndromes, we can not help mentioning the fact about such treatment side effects. Below there are the most common side effects:
- Dry mouth
- Decreased urination
- Blurry vision
- Sleep disorders
- Weight gain
- Diarrhea, disruption of the gastrointestinal tract
- Stomach ache
- Erectile dysfunction
- Loss of libido
- Increased irritability
Just to note, due to various reasons in some problematic cases, psychotherapy might have a short-lasting impact or no effect at all.
Does CBD offer a way out?
A lot of debates about the possibilities of using CBD as an alternative to antidepressants have been going around. With the decriminalization of cannabis and the widespread availability of chemicals derived from this plant, it is essential to look at the empirical evidence to define if cannabinoids can live up to their hype as an option for anxiety-related disorders treatment in the future. So, could this really be an option?
Nowadays, cannabidiol (CBD) is a well-studied phytocannabinoid constituent of Cannabis sativa. However, let us not get scared by old cannabis paradigms. CBD lacks the psychoactive effect, unlike its compound relative 9-tetrahydrocannabinol (THC), which gives this well-known "high" effect. You probably heard that cannabis plants could sometimes be called hemp or marijuana, and it depends on the level of THC present. The average marijuana strain today contains about twelve percent of THC. Although CBD oil may contain small amounts of THC, CBD should not have more than 0.2 percent of THC to be legal at the federal level.
A potential side effects review found that humans tolerated CBD well, even across a wide range of dosage, up to 1500 mg/day (orally), with no reported psychomotor slowing, adverse mood effects, or vital sign abnormalities noted. Studies by Maurya N. et al., 2018 suggest that an adequate daily treatment dose can be anywhere from 30 to 160 mg, which depends on the symptoms a person is trying to alleviate.
Therefore, this assumes that the dosage of CBD oil most people are using today is unlikely to be clinically efficient. More likely that at doses of just 2 to 10 mg per day, people mostly benefit from a placebo effect. However, it all comes to a variety of symptoms that a person is trying to get rid of.
CBD is commonly available in four textures:
- Oral. Tinctures, capsules, sprays, and oils. Natural oil can taste a little "weedy," which might be tough for consumption for some people. There are also oils on the market that are infused with other ingredients if you want to dial back any unpleasant flavors. CBD oils have a wide variety of new tastes and different strengths.
- Edible. Drinks and foods, such as CBD-infused gummies.
- Vaping. It is the fastest way to ingest the compound. However, it is still not clear about the long-term safety of such a method. Also, it can cause coughing and throat irritation.
- Topical. CBD-infused beauty products, lotions, and creams are trendy now. These products incorporate CBD into things you apply directly to your skin. However, this formulation is likely best for pain, not mental health uses.
Science behind CBD
An article in the Neuroendocrinology journal highlights the critical role of our inner endocannabinoid system in protection against post-traumatic stress disorder (PTSD). It is suggested that also, chronic stress is associated with decreased endocannabinoid levels in our bodies. Cannabinoid receptor signaling is a critical modulator of adaptation to stress. Besides, the endocannabinoid system regulates our appetite, body temperature, blood pressure, metabolism, pain, and mood, hence, essential factors that have a significant impact on everyday life.
Studies show that CBD has a broad pharmacological profile. It interacts with several receptors in our endocannabinoid brain system known to regulate fear and anxiety-related behaviors such as
- Cannabinoid type 1 receptor (CB1R)
- Serotonin 5-HT1A receptor
- Transient receptor potential vanilloid type 1 (TRPV1) receptor
The best-studied endogenous ligands for these receptors are anandamide and 2-arachidonoylglycerol (2-AG). They both have different binding affinities for these targets. 2-AG works as a full agonist of CB1 and CB2 receptors in the endocannabinoid system. At the same time, anandamide has a lower affinity for cannabinoid receptors but acts as a full agonist at TRPV1 receptors.
Let's get deeper into science. CB-1 is a mediator of a broad range of physiological functions like emotional learning, stress adaptation, and fear extinction. Normally functioning CB-1 receptors deactivate traumatic memories and even more aids to forget. On the other hand, skewed CB-1 signaling, due to endocannabinoid deficits, for example, low serum levels of anandamide, can result in impaired fear extinction, aversive memory consolidation, and chronic anxiety, all of the PTSD hallmarks.
Research carried by a team of U.S. and Canadian scientists investigated neurobiological mechanisms that underlie the onset and development of PTSD. They analyzed 46 subjects who were near the World Trade Center in New York City during the September 11 terrorist attacks. Twenty-four of these subjects had diagnosed PTSD, and twenty-two did not. The research team has already observed that people with PTSD had lower serum levels of anandamide in comparison to those who did not display any signs of PTSD after the 9/11 tragedy. Our "inner cannabis" - anandamide triggers the same brain receptors, which are THC - activated. So this study proves that the endocannabinoid system is dysfunctioned in PTSD patients.
The effect of CBD given on specific receptors shown to be dose-dependent. Results indicate that the anxiolytic effects of systematically carried low CBD doses activate 5-HT1A receptors, whereas higher doses might not affect anxiety by also activating TRPV1 channels.
CBD research gave rise to a myriad of preclinical studies in different rodent models. Stern et al., 2015 investigated its effect on innate fear and anxiety-producing behavior (e.g., open field, light-dark test, maze, and exposure to predators). When CBD was given systemically or infused locally into various brain areas that govern fear and anxiety, its anxiolytic potential was confirmed. Especially given under the circumstances or in response to stimuli, which generally provokes anxiety.
From rats to human trials
There are currently two ongoing human studies that investigate the action of both THC and CBD on post-traumatic stress disorder symptoms.
The first study explores different potencies of smoked marijuana in 76 war veterans. Four different types of cannabis are evaluated using a "triple-blind" cross-over placebo-controlled design. After screening and meeting study requirements, participants are assigned to randomly receive one of four types of various THC and CBD content cannabis. During three weeks, each participant will have to smoke two out of four types of marijuana, up to 1.8 grams per day. Participants can smoke their daily prescribed 1.8g cannabis at any time. After every 3-week cannabis consumption period, they will have to stop smoking marijuana/cannabis for two weeks. No cannabis will be allowed during this period. This study looks very promising as it will hopefully aid in a better understanding of risks and benefits associated with cannabis consumption among veterans with PTSD.
The second study was entitled to evaluate the safety and efficacy of vaporized cannabis in chronic PTSD patients. Different ratios of CBD: THC content were tested ( High THC/Low CBD, High THC/High CBD, and Low THC/Low CBD) in a randomized and triple-blinded manner. Two grams of dried cannabis per day were administered. According to the principal investigator of this study Lucas Elms, CBD appeared to show relief in a subgroup of test patients who reported frequent nightmares as one of the symptoms of their disorder. However, this study has only started in 2019, and more results are about to come.
In 2016 Shannon and Opila-Lehman published a case report about a 10-year-old child who has been sexually abused before the age of five. As a result, this child developed PTSD. Before the CBD oil therapy, which afterward showed a significant relief, the child went through standard pharmacological treatment for the condition. Unfortunately, such treatment produced only a short-lasting partial relief, as well as significant side effects. As studies showed, CBD oil, prescribed at a dose of 12–25 mg once a day, happened to exempt main symptoms, such as anxiety and sleep disturbance, while inducing minimal side effects. Even though CBD is considered to be safe (Bergamashi et al., 2011), more investigations need to be done on the long-term effects (Shannon and Opila- Lehman, 2016).
In 2017, the World Health Organization concluded that CBD is generally safe to use. Important to say, WHO noted that interactions between CBD and other medications might cause adverse effects. So before starting or trying any type of supplements, including CBD or THC - please first consult your prescribing physician or psychiatrist.
Most of the human-based research is still in its infancy, and many more to come, however, have to admit that early signs are promising. Even facing evidence that points to the modulation of the endocannabinoid system, more studies are required. They should be more focused on the development and better understanding of the CBD neurobiological mechanisms. To make the research more accurate, additional controlled studies of CBD and PTSD in humans are needed. Many steps have already been made in this direction, and much remains to be discovered. It may yield a formulation of CBD for the treatment of patients with trauma and stress-related disorders.
Why you should prefer CBD over antidepressant
PTSD is a severe psychological disorder that deserves a meticulous and delicate treatment, which has to be assessed and assigned by an appropriate specialist. Psychotherapy and antidepressant prescription always seemed like a working model, but let's look at the numbers which are just behind the scenes of the pharmaceutical business.
According to the CDC statistics:
- In 2012 about 259 million pain-relieving prescriptions were given by health care providers.
- In 2015, two million U.S. citizens aged ≥12 years had a substance use disorder that involved prescription pain relievers.
- The CDC reports that over the last 15 years, overdose from prescription opioids was a "driving factor" in the increase in opiate overdose deaths accidents.
- Such cases of death have increased four times in the same period with >20,000 overdose deaths attributable to prescription pain relievers alone.
Even though cannabis is still illegal in many states and the professional guidance on dosage is still under consideration, people seem to take it upon themselves to augment or discontinue U.S. Food and Drug Administration (FDA)-approved drugs in favor of a mostly unregulated herbal treatment.
Research by James M.Carroon et al., 2017 anonymously tested 2,774 individuals who reported using cannabis at least once in the previous 90 days. The result was somewhat surprising- a total of 1,248 (46%) respondents said cannabis consumption as a substitute for prescription drugs. The most common classes of substituted by plant drugs were opioids (35.8%), anxiolytics/benzodiazepines (13.6%), and antidepressants (12.7%).
It might be more beneficial to take CBD instead of antidepressants, and here is why:
- CBD is a naturally occurring substance (no common allergic reactions or misuse);
- No long-lasting side effects;
- Does not cause addiction;
- Potentially can have the same effect as chemical antidepressants.
If you are taking antidepressants and are thinking about substituting it with CBD, however, it is necessary to talk with your doctor rather than quitting to take them on your own. Your body can go through withdrawal symptoms, and you don't need that.
In 2017, The World Health Organization declared CBD as a non-toxic, safe, and addiction-free compound. However, as with any things that we consume, there are potential side-effects of CBD products. Fortunately, there are just minor unwanted side reactions like low blood pressure, dry mouth, and drowsiness. Nevertheless, if CBD is a brand-new alternative to opioid drugs and addictive antidepressants in anxiety and post-traumatic syndrome treatment, then such adverse effects are the little stumbling block on the way to stress relief and flashbacks respawn.