Full text of consultant psychiatrist Ben Sessa’s talk: Is MDMA psychiatry’s antibiotic? at TEDxUniversityofBristol conference.
Listen to the MP3 Audio here:
Ben Sessa – Consultant psychiatrist
Now you’ve 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 a 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 going to 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 disorders, 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 as 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 of what we call psychosomatic symptoms in depression, and, as a result, the family doctor put her onto opiate-based painkillers which she promptly became addicted to.
Now, Claire’s father, 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, a 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 posttraumatic stress disorder, or PTSD.
Now, PTSD, some of the core features: very low mood, anxiety, high levels of anxiety, what we call hypervigilance – this edginess, this jumpiness. Exactly how Claire felt, throughout her childhood and adolescence, never knowing whether the next assailant or assaulter 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 use in 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, fever is caused by an infection, by a microorganism. Sure, you can take paracetamol or ibuprofen, and this will lower the temperature, 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’ tale 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.