Recreational 3,4-methylenedioxy-N-methylamphetamine (MDMA) or ‘ecstasy’ and self-focused compassion: Preliminary steps in the development of a therapeutic psychopharmacology of contemplative practices

This open-label, observational, within-subjects study (n=20) investigated the effects of MDMA on compassionate attitudes before and after recreational use, compared to a sober state, and found that it reduced self-criticism and increased self-compassion in exposure to compassionate imagery.

Abstract

Introduction: 3,4-methylenedioxy-N-methylamphetamine (MDMA) produces diverse pro-social effects. Cognitive training methods rooted in Eastern contemplative practices also produce these effects through the development of a compassionate mindset. Given this similarity, we propose that one potential mechanism of action of MDMA in psychotherapy is through enhancing effects on intrapersonal attitudes (i.e. pro-social attitudes towards the self). We provide a preliminary test of this idea.

Methods: Recreational MDMA (ecstasy) users were tested on two occasions, having consumed or not consumed ecstasy. Self-critical and self-compassionate responses to self-threatening scenarios were assessed before (T1) and after (T2) ecstasy use (or non-use), and then after compassionate imagery (T3). Moderating roles of dispositional self-criticism and avoidant attachment were examined.

Results: Separately, compassionate imagery and ecstasy produced similar sociotropic effects, as well as increases in self-compassion and reductions in self-criticism. Higher attachment-related avoidance was associated with additive effects of compassionate imagery and ecstasy on self-compassion.

Discussion: Findings were in line with MDMA’s neuropharmacological profile, its phenomenological effects and its proposed adjunctive use in psychotherapy. However, although conditions were balanced, the experiment was non-blind and MDMA dose/purity was not determined. Controlled studies with pharmaceutically pure MDMA are still needed to test these effects rigorously.”

Authors: Sunjeev K Kamboj, Emma J Kilford & Stephanie Minchin

Summary

Introduction

Recreational users of MDMA report enhanced interpersonal relatedness, which may be related to its unique pharmacology as a broad-acting pro-monoamine-, vasopressin- and oxytocin-ergic compound. Self-soothing processes are also involved in social approach, reward and attachment in mammalian brain systems that evolved specifically to promote affiliation among conspecifics.

MDMA (ecstasy) produces pro-social effects through the development of a compassionate mindset. This study examined the effects of MDMA on self-compassion in recreational users and found that higher attachment-related avoidance was associated with additive effects of compassionate imagery and ecstasy on self-compassion.

Recently, novel psychotherapeutic procedures inspired by Eastern meditative practices have been developed. These procedures use compassionate imagery to direct benevolent, nurturing, warmly regarding and compassionate feelings towards the self.

Expert meditators show evidence of neural remodelling and alterations in neural and epigenetic responses to social stress, and can achieve states of ecstasy and transcendence during meditation. Alternatively, profound personal insights can also be gained through the use of psychedelic drugs.

MDMA, a mixed-profile psychedelic/stimulant drug, has been tested in small-scale clinical trials as an adjunct to psychotherapy, but is most commonly used as a recreational drug, namely ecstasy. Its pro-social effects include feelings of love and compassion, which motivate its use amongst those seeking spiritual awakening.

We used a within-subjects, repeated measures, naturalistic experimental design to examine the combined effects of MDMA and ecstasy on self-criticism and self-compassion in recreational ecstasy users. We predicted that effects of CI – a psychological procedure used in a bona fide psychotherapy – would be enhanced by ecstasy.

We examine whether any interaction between CI and ecstasy is moderated by attachment characteristics. We find that those with problematic forms of adult attachment may experience barriers to (self-) compassion and may benefit from compassion-oriented treatments to overcome these barriers.

Ecstasy, a recreational drug, contains varying amounts of MDMA along with other stimulant compounds. Studies on the neurotoxicity of MDMA must be considered in the context of the relative impurity of the drug being examined.

Participants

Ecstasy users were recruited through word of mouth and snowball sampling and were screened via telephone interview.

Twenty participants (seven women, 13 men) began and completed the study, and all gave written, informed consent at the start of the first session. The study was approved by the University College London Graduate School Research Ethics Committee.

Design and procedure

A naturalistic within-subjects design was used with participants taking ecstasy recreationally prior to a CI task. The control session was completed either before or after the CI + ecstasy session.

Participants were asked to refrain from any drugs for 24 hours prior to each session, and provided a urine drug-screen at the start of each of the two sessions. A scenario-based measure of self-compassion and self-criticism was administered at three time points: baseline, 40 13 min after T1, and 20 min after T2.

State measures

The effects of ecstasy on affective state and self-attitudes were assessed using pre-/post-state measures and drug-specific subjective measures.

A set of visual analogue scales was used to assess ecstasy-related mood and symptoms, including compassion and empathy.

On the CI + ecstasy session, participants rated the strength of their ecstasy and its purity before and after taking the drug.

Participants responded to questions about their experience of compassionate imagery on Likert scales, and were asked to describe the ease with which they experienced their image.

Positive and negative affect were measured using the PANAS and TPAS. The TPAS consists of 18 words, which participants rate on a 5-point scale to indicate the extent to which each word characterises them.

The SCCS is a situational measure of self-compassion and self-criticism that consists of five scenarios that are potentially self-threatening. Participants respond to the scenarios with varying degrees of self-compassion and self-criticism on seven-point Likert scales.

Mood, trait and drug use measures

The Beck Depression Inventory II (BDI-II) measures symptoms of depression. Higher total scores indicate more severe symptoms of depression.

The ‘close relationships’ version of the Revised Adult Attachment Scale was used to measure how comfortable an individual is with closeness. The ‘close’ subscale was of particular interest in this study given the moderating role of attachment-related avoidance in oxytocin’s effects on self-compassion.

Trait self-criticism was measured using the inadequate-self subscale of the Forms of Self-Criticizing/ Attacking and Self-Reassuring Scale. High self-criticism moderated the response of oxytocin on experiences of self-compassion.

Participants’ drug use was assessed using a drug screen urine test cup. They were asked about their most recent consumption, length of use, and days per month use of different drugs.

Compassionate imagery

Participants listened to three MP3 recordings, one of which described an ideal compassionate being. They then developed an image of an ideal compassionate being and then an image of receiving compassion from this being, focusing sequentially on various qualities of (or feelings arising from) deep commitment, strength and dependability.

Statistical analyses

Data were analysed using 2 3 repeated measures ANOVA, with Session (CI ecstasy) and Time (T1, T2 and T3) as within-subject factors, and positive/negative mood states, state self-compassion and self-criticism as dependent variables.

Participants’ mean age was 25.50 years, they had negligible levels of depression, and all reported regular use of alcohol, tobacco and ecstasy. Urinalysis results were generally consistent with self-report drug use.

Drug experience and expectancy ratings

Participants’ ratings of their ecstasy experience did not differ from the pre- to post-session interval for rated strength or rated purity.

Ecstasy-related mood and symptoms

There were main effects of time on all 11 ecstasy-related mood and symptom factors, and also main effects of session on euphoria, jaw clenching, and sensitivity to colours.

Euphoria increased at time 2 after a CI + ecstasy session, and jaw-clenching and sensitivity to colours decreased at time 2 after a CI + ecstasy session.

Ecstasy and CI had parallel, independent effects on wanting to be with others. None of the 11 ecstasy-related mood and symptom factors increased significantly between T2 and T3 on the CI + ecstasy session.

imagery on positive affect

There were no main effects of time or session on the active positive affect subscale of the TPAS, but there was a significant interaction between time and session.

Effects of ecstasy and compassionate imagery on negative affect

Time had a significant effect on negative affect scores, but no effect of session or session-time interaction was observed.

Effects of ecstasy and compassionate imagery on state self-criticism and self-compassion

The self-criticism scale of the SCCS was significantly reduced in response to ecstasy between T1 and T2, and was also reduced in response to CI between T2 and T3, suggesting that these effects on positive affect and self-criticism were independent.

There was a main effect of Time and Session on self-compassion scores, but no Time – Session interaction. Ecstasy alone had an effect on self-compassion, but no additional effect of CI.

Moderating role of attachment-related avoidance

The moderating role of attachment-related avoidance with respect to state self-criticism was not found. However, there was a three-way Session – Time – Group interaction for state self-compassion.

Moderating role of trait self-criticism

The moderators of interest were dispositional self-criticism and self-compassion. There were no significant interactions involving Group.

Discussion

In this study we examined the effects of recreational ecstasy use and compassion in the presence of others on self-criticism and self-compassion. The effects were moderated by adult attachment characteristics, with greater attachment-related avoidance showing enhanced self-compassion following ecstasy use and compassion thereafter.

Ecstasy and CI effects on self-criticism and self-compassion did not appear to reflect generalised improvements in mood. Instead, they were consistent with pharmacologically induced modulation of self-processing.

Ecstasy seems to facilitate positive self-referential processing, which is important for the treatment of psychiatric disorders. However, for some individuals the initial experience of self-compassion can be challenging, and improved methods for overcoming barriers to self-compassion continue to be needed.

Intrapersonal relating may be enhanced by MDMA, with positive affiliative behaviour recruiting a well-characterised set of neural systems and processes involved in affiliative and consummatory reward and positive social memory.

Those with higher levels of attachment-related avoidance showed the clearest evidence of additive effects of ecstasy and cognitive-behavioural self-compassion-enhancing practices, specifically on state self-compassion. Attachment avoidance moderated the effects of oxytocin on experiential aspects of selffocused CI. Those who were less avoidant experienced greater positive effects of CI following intranasal oxytocin, although the effects were opposite to those found in the presence of ecstasy.

MDMA enhances psychotherapeutic outcome in treatment-resistant post-traumatic stress disorder, but its mechanism of action is unknown. CI may optimise MDMA-assisted psychotherapy, however, because it is experientially consistent with MDMA-induced states.

We are aware of the need to be cautious in generalising these findings to non-drug-using healthy populations or those seeking treatment for psychological disorders. However, we decided to test our hypotheses in a group of recreational ecstasy users to determine if there was a compelling rationale for testing. Several participants tested positive for recreational/ medicinal compounds, including THC, benzodiazepines and opioids. However, they did not show all of the effects expected of MDMA.

The combined effects of ecstasy and CI might have resulted in the effects on self-compassion and self-criticism on the session where ecstasy was taken prior to CI.

Since ecstasy likely contains other psychoactive compounds, the effects observed here cannot unequivocally be attributed to MDMA alone. Future studies should seek to verify the chemical composition of the formulations used by recreational users.

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