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Getting PTSD added to lists of ailments for medical cannabis has gotten to be an outrageous hassle. Colorado just voted against including it on their medical list, and it’s stirred me up in a way that’s incredibly uncomfortable. I’m sure Ladybud readers know what PTSD is, and I could go into all the base rates and symptoms, but I don’t want to bore you. The description below is potentially reactivating for anyone with the disorder, so feel free to skip to the next paragraph.
Bottom line: This is an unparalleled anxiety reaction to shocking ordeals. The exact diagnosis changed fairly recently but the idea is still the same. I don’t mean a lump in the throat. We’re talking night terrors, sudden “re-experiencing” of the trauma as if you’ve done some kind of torturous time travel, incomprehensible depressive symptoms, avoidance of anything loosely reminiscent of the trauma or anything vaguely associated with it, thoughts about the god damned thing that jump into your head as if some omnipotent deity must really want you to suffer, and all kinds of flooding guilt, anger, grief, embarrassment, blow ups and crying jags. Oh! And let me add numbing, where you don’t feel anything because you’re completely exhausted. If you can imagine having no control over your emotions and they’re all overpowering and bad, you’re in the ballpark. And it fucking bites. In the US, about 7% of men and 10% of women will get it in their lives.
Psychotherapy’s my first choice for PTSD. Some variation of exposure treatment almost invariably leads to the best outcomes. (Effect sizes average better than one standard deviation, if you speak geek. That’s about twice as good as throwing the best pills at folks.) In the therapy, clients learn relaxation techniques over a few weeks, then gradually talk about the trauma or traumas. They work through them all over and over and over again until they no longer create that averse, weepy arousal that is so debilitating.
The problem is, exposure therapy sucks. It’s a complete drag. Clients hate it. Therapists have to be supremely vigilant to keep them on the path. The sessions have to run until the arousal dies down each time, so, ideally, a lot of therapists think the session should run 90 minutes. Insurance generally screws the therapist on these and reimburses for, I kid you not, a 37-minute session. (It depends on the company, obviously, but this happens.) So anybody who’s willing to do this has to be some kind of saint. Unfortunately, at some VA Hospitals it’s fobbed off on some 20-something intern who’s never done it before, never been shot at or had an unwanted dick poked at them, and has literally thirty other clients to see that week.
Every week some freaky life event is bound to come up for the client, which makes the therapy even crazier. (Imagine walking around aroused and weepy all day and dealing with your usual bullshit. As if life’s not hard enough…). The clients are always dying to discuss the stuff that’s happening now, and it would obviously help. But they really need to do the exposure. If you’re the therapist who makes them do the exposure when they have some pressing issue arise in the present, they start to think you don’t care about them. Then they’re more likely to drop out. It’s one of those “tough love” situations that can be a real hassle.
The only way around it, as far as I can tell, is to work for several weeks establishing a good relationship and explaining ahead of time that you’re going to be an asshole of a therapist once the exposures start, and that you’re doing it out of love. This means the standardized, manualized, 12-week exposure program ends up lasting six months for anyone who has anything complicated to deal with, and all the cases are pretty complicated. Six months are hardly a lot of therapy but if you try to get the National Institute of Health to fund a randomized clinical trial that has that much therapy, some other researcher will claim he or she can do it in three months and get the funding instead of you. Sorry if I sound bitter. If you’re the VA intern who’s trying to get this done, you’re likely to move to another clinic after three months, so you can imagine what a mess this leaves.
If we spent a fraction of our war budget on doing this treatment the way it really needs to be done, this whole country would benefit. We could all feel a lot better about paying our taxes, too.
As you’d guess, we’d love to have a pharmaceutical intervention that could either handle the whole disorder or at least make it so the exposure therapy is tolerable. We’ve got some meds that do something but aren’t as good as the psychotherapy. (Effect size averages .38. The best meds, usually antidepressants, average around .6.) There aren’t a lot of experiments published on these drugs, so these results could be the best of the bunch while insignificant findings sitting in the researchers’ drawers because they’re never going to publish. All these drugs have side effects, including some ironically depressing ones like loss of interest in sex.
People claim that cannabis helps. A study of mine where I just asked 650 people what symptoms respond well to cannabis revealed, well, exactly what you’d guess. A good strain can keep the general arousal down, hold those intrusive thoughts at bay, and improve sleep. Although doing the exposure sessions while high is probably a waste of time because the plant likely disconnects the memory and fear centers in the brain, I bet a vaporized puff or twelve between sessions would keep most folks coming back to the treatment. I wish I could do a big randomized clinical trial with a million people to prove it. But hell, I wish Santa would bring me enough cash to retire.
Usually we do big randomized clinical trials to make sure a drug isn’t working simply because of the placebo effect. I can’t, however, think that this is all placebo. It’s just kind of stupid idea. Running a study like this with placebo pot wouldn’t fool anybody, either, so it seems like we’d have to do a horse race between this medicine and some other one. I’d much rather do an exposure treatment and have a group who gets cannabis to help them between sessions and a group that doesn’t. But I might as well be writing Santa again. We tend to do this kind of research to help weigh the pros and cons of drugs. Each drug has side effects so we want to make sure it helps enough to make it worth taking. But what’s the big side effect of cannabis again? Euphoria? Munchies? An appreciation for nature? Weigh those against night terrors and tell me which is worse.
With this information in mind, we’re left with an odd predicament. We’d love to have better data on how cannabis might help PTSD. While we’re waiting for that research to finish, we could let people have the plant anyway, or threaten them with legal sanctions for doing the best that they can do to handle their symptoms. Which one sounds more humane?
Earleywine, M., & Bolles, J. R. (2014). Marijuana, Expectancies, and Post-Traumatic Stress Symptoms: A Preliminary Investigation. Journal of psychoactive drugs, 46(3), 171-177.
Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2014). A multidimensional meta-analysis of psychotherapy for PTSD. American journal of Psychiatry.
Puetz, T. W., Youngstedt, S. D., & Herring, M. P. (2014). Effects of Pharmacotherapy on Combat-Related PTSD, Anxiety, and Depression: A Systematic Review and Meta-Regression Analysis. PloS one, 10(5), e0126529-e0126529.
More Ladybud Magazine articles on PTSD:
Feature image: Diane Fornbacher, Self Portrait