Additive Effects of 3,4-Methylenedioxymethamphetamine (MDMA) and Compassionate Imagery on Self-Compassion in Recreational Users of Ecstasy

This open-label study (n=20) suggests that the effects of compassionate imagery and MDMA may be additive in regards to self-compassion and emotional empathy.

Abstract

“3,4-Methylenedioxymethylamphetamine (MDMA;‘ecstasy’) produces prosocial subjective effects that may extend to affiliative feelings towards the self. Behavioural techniques can produce similar self-directed affiliation. For example, compassionate imagery (CI) and ecstasy reduce self-criticism and increase self-compassion to a similar extent, with the effects of CI enhanced in the presence of ecstasy. Here, we examine self-compassion and self-criticism in recreational users who consumed chemically verified MDMA in a within-subjects crossover study. In a naturalistic setting, polydrug-using participants performed a self-focused CI exercise on two occasions separated by ≥6 days: once having consumed self-sourced MDMA and once not. Effects on state self-criticism, self-compassion and emotional empathy were assessed before and after MDMA use (or over an extended baseline period on the occasion that MDMA was not consumed) and reassessed after CI. In participants (n = 20; 8 women) whose ecstasy contained MDMA and no other drug, CI and MDMA appeared to separately increase emotional empathy (to critical facial expressions) and self-compassion. The effects of CI and MDMA on self-compassion also appeared to be additive. Establishing the observed effects in controlled studies will be critical for determining the combined utility of these approaches in fostering adaptive self-attitudes in a therapeutic context.”

Authors: Sunjeev K. Kamboj, Ylva S. E. Walldén, Caroline J. Falconer, Majdah Raji Alotaibi, Ian S. Blagbrough, Stephen M. Husbands & Tom P. Freeman

Summary

MDMA (ecstasy) produces prosocial subjective effects that may extend to affiliative feelings towards the self. Compassionate imagery (CI) and MDMA reduce self-criticism and increase self-compassion to a similar extent, with CI’s effects being enhanced in the presence of ecstasy.

Introduction

Ecstasy is a popular recreational drug that produces subjective interpersonal effects. These effects are similar to those seen in controlled laboratory experiments.

MDMA may have therapeutic potential as an adjunct to psychotherapy for disorders characterised by heightened threat, concerns about social evaluation and deficits in understanding of interpersonal communication.

Compassion focused therapy involves encouraging patients to generate compassionate responses to self-attacking thoughts. This is done by integrating insights from Buddhist psychology with cognitive therapy.

Compassion-focused therapy techniques, such as compassionate imagery, may be generated or augmented by oxytocin release. These observations contribute to our understanding of neurobiological mechanisms for building resilience and improving well-being, but also point to strategies for overcoming the pernicious negative emotional/cognitive states that characterise psychopathologies.

Despite the potential benefits of using compassion-oriented contemplative techniques as therapeutic strategies, some individuals may find self-directed compassion-oriented strategies challenging, despite training. Neuropsychopharmacological augmentation of psychosocial compassion-oriented strategies might mitigate against such barriers. In a preliminary study, recreational ecstasy use was associated with an acute enhancement in self-compassion and reduction in self-criticism. However, the size of these effects depended on participants’ adult attachment characteristics. Naturalistic studies, such as those conducted in ecological settings and/or with participants who are under the influence of a drug they have sourced themselves, may be valuable in allowing efficient preliminary hypothesis testing on as yet poorly characterised drug effects.

We aimed to replicate previous findings on self-compassion and self-criticism following ecstasy use and/or CI, while also assessing the composition of participants’ self-administered ecstasy using high-precision spectroscopy. We also examined the effects of recreational MDMA use and/or CI on general interpersonal processing of criticism and compassion.

Participants

Interested recreational ecstasy users were recruited by word-of-mouth and snowballing from the local community. Those with a history of mental health problems or physical illness were excluded.

Twenty-five participants began and completed the study (14 men; 11 women). Of these, 20 participants had previous regular experience with MDMA (median length of experience, 4 years; median regularity of use, 1/month); 15 participants used MDMA 2 times/month; 16 were smokers; 5 women used hormone-based contraception; 3 were ‘regularly cycling’.

Procedure

The procedure closely followed that used in Kamboj et al. (2015), with participants taking MDMA 1 h before a compassionate imagery task and no drug prior to CI in a naturalistic (non-laboratory), within-subjects design.

The participants were asked to refrain from drugs for 24 h prior to the testing session, and a urine sample was provided at the start of each of the two sessions. A scenario-based measure of self-compassion/self-criticism was taken at T1 (baseline), T2 (1 h after T1) and T3 (20 min after T2).

Participants consumed MDMA by insufflation or oral administration and provided the experimenter with the amount they intended to consume.

After MDMA use, participants listened to guided CI instructions and completed state affect measures again at T3, where the combined effect of MDMA and CI was compared to CI alone.

Measures

A series of visual analogue scales assessed ecstasy-related mood and symptoms, with ‘not at all’ and ‘very’ at the extremes.

State Self-Compassion and Self-Criticism The Self-

The SCCS is a scenario-based state measure of self-compassion and self-criticism that consists of five scenarios designed to induce negative self-referential thinking. It has been validated and demonstrates good psychometric properties.

The TPAS assesses the extent to which people experience different types of positive affect, including active, relaxed, calm, tranquil, laid back, serene, and content/warm affect.

Adult Attachment The ‘close relationships’ version of the Revised Adult Attachment Scale was used, which has three subscales (‘close’, ‘depend’ and ‘anxiety’; six items each). Higher scores indicate higher levels of attachment, while lower scores indicate higher levels of attachment anxiety.

The ‘close’ and ‘depend’ subscales were strongly correlated, whereas the correlation with attachment anxiety was small.

Participants’ urine was tested for the presence of common recreational drugs, including alcohol, tobacco, ecstasy, cannabis, cocaine, ketamine, hallucinogens, mephedrone and amphetamine.

We adapted the Empathy Assessment Task using the Self-Assessment Manikin (EAT-SAM) from Ali et al. (2009) and used nine different female actors to evoke anger and happiness. We created a new stimulus set consisting of nine facial expressions of each, which were generated by averaging the photographed faces of three different female actors using the image averaging software, PsychoMorph. These stimuli were then morphed towards a composite prototype image of a face expressing either compassion or criticism.

The Self-Assessment Manikin (SAM) task consisted of 72 trials consisting of 9 different stimuli for each of four basic/complex expressions. The participants were instructed on the meaning of the SAM pictograms and were then presented with facial expressions to indicate their current emotional state.

Compassionate Imagery Task

Participants completed a guided CI exercise, in which they listened to audio-recorded instructions, performed a relaxation exercise, and generated an image of an ideal compassionate being.

Analysis of Ecstasy Samples

Prior to consumption, a small amount of ecstasy was retained for subsequent analysis using 1H nuclear magnetic resonance spectroscopy and 13C, DEPT, COSY, HMBC and HSQC spectroscopy.

Data Analyses

The Statistical Package for Social Sciences (SPSS, version 24, IBM) was used to perform all statistical analyses. Two-way Time Session repeated measures ANOVAs, three-way Time Session arousal ANOVAs and ANCOVAs were used to assess moderation by attachment security of the effects of MDMA and CI on self-compassion.

The authors used planned comparisons to follow up the main analyses on self-compassion and self-criticism, and Bonferroni-corrected ANOVA effects for significant differences. Pearson’s correlations were used to explore association between variables.

Key analyses were repeated excluding the participant with the outlying MDMA dose (0.25 g) and the three participants who insufflated their MDMA.

Results

The mean age of the participants was 28.45 years, and they had a mean BDI score of 9.50. All participants reported abstinence from drugs in the 24 h prior to both testing sessions, but all also reported use of some illicit substance in the 2 weeks preceding one or both sessions.

Subjective Effects of MDMA: Visual Analogue Scales

Significant Time – Session interactions were observed for thirst, energetic, muscle tension, jaw clenching, blurred vision, sensitivity to colour, hunger, high and alertness. These interactions reflected a general pattern of increases (or a decrease, in the case of hunger) from T1 to T2/T3, only on the MDMA + CI session.

Physiological Effects

An expected session-time interaction was found for heart rate, with heart rate being higher in the MDMA + CI session compared to the CI-only session.

Effects on Self-Criticism and Self-Compassion

There were main effects of Time and Session on the state self-criticism and compassion subscales of the SCCS, but a Time – Session interaction was also significant. On the CI-only session, self-compassion did not change during the extended baseline, but increased between T2 and T3, after CI. On the MDMA + CI session, self-compassion increased between T1 and T2, and increased again between T2 and T3.

We found no Session – Time interactions on any of the TPAS subscales, except for the active subscale, which showed higher levels of active positive affect post-MDMA.

Moderating Role of Attachment on Self-Compassion

We did not observe a moderating role for the Closeness aspect of attachment avoidance in the Time Session interaction on self-compassion, although high AAS – dependence scores were associated with larger increases in self-compassion.

Emotional Empathy

The EAT-SAM showed no effects of session or time for basic emotions, but an effect of emotion on arousal. There was a significant Time Session Emotion interaction for the complex emotion duo (critical and compassionate faces), which was investigated further with separate Time Session ANOVAs.

The effects of CI alone were smaller than the effects of MDMA alone on EAT-SAM arousal, and there was only a main effect of Emotion for the complex emotions on the valence measure of the EAT-SAM (compassionate > critical).

Discussion

In this report, we extend previous findings on the effects of recreational ecstasy and compassionate imagery on self-attitudes. We found that the effects were similar across both studies, although the statistical pattern of interactions diverged.

MDMA and CI appeared to produce similar increases in self-compassion, but when CI was administered in the presence of MDMA, the increase in self-compassion was larger.

The effects of CI on self-compassion were found in the absence of interactions on three relevant and psychometrically distinct types of positive affect (relaxation, contentment/warmth and activation). However, the effects on self-criticism were less clear-cut.

Previous studies have examined the effects of MDMA on emotional empathy, but these have tended to use situational rather than facial stimuli and have not specifically examined compassion and criticism. The present study used critical facial expressions and found different effects than previous studies.

The effects of CI and MDMA on state self-compassion and arousal to critical facial stimuli are similar, which suggests a common biopsychological mechanism. However, the effects of CI and MDMA are likely due to distinct effects on the autonomic nervous system.

MDMA’s effects are similar to those of compassion-oriented practices, and may be used to augment or mimic the effects of compassion-oriented practices in those with specific vulnerabilities who might otherwise fail to benefit from compassion-oriented psychosocial treatments.

Limitations

While this study represents a methodological improvement over the previous study design, it has some clear limitations. It is not possible to know how the findings would generalise to MDMA-naive participants or to those with whom compassion-oriented strategies are typically used in the context of psychopathology.

Participants chose the amount of MDMA they consumed, which introduced some variability in the effects of the drug. However, the absence of confirmatory chromatographic/spectrometric analysis of positive drug screens leaves some uncertainty about the role other drugs might have played in the effects reported here.

We used the most efficient design possible to test our hypotheses, and did not use additional control conditions. Future studies should consider the issue of the number of control conditions and experimental sessions.

Further research is needed to determine the effects of MDMA on intrapersonal attitudes, and rigorous tests may inform the way that MDMA is used in combination with psychotherapeutic strategies.

Study details

Compounds studied
MDMA

Topics studied
Personality

Study characteristics
Open-Label Within-Subject

Participants
20

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