The Potential Dangers of Using MDMA for Psychotherapy

This review (2014) examines both the negative and positive aspects of using MDMA for psychotherapy, with specific regard to its neurohormonal profile, the effects of serotonergic depletion, and neurotoxicity of repeated usage. The most critical issues are related to the release of difficult feelings and memories and the lack of control thereof due to heightened environmental sensitivity, as well as the risk that negative mood states predominating the phase of neurochemical recovery amongst certain individuals.

Abstract

Introduction: MDMA has properties that may make it attractive for psychotherapy, although many of its effects are potentially problematic. These contrasting effects will be critically reviewed in order to assess whether MDMA could be safe for clinical usage. Early studies from the 1980s noted that MDMA was an entactogen, engendering feelings of love and warmth. However, negative experiences can also occur with MDMA since it is not selective in the thoughts or emotions it releases. This unpredictability in the psychological material released is similar to another serotonergic drug, LSD. Acute MDMA has powerful neurohormonal effects, increasing cortisol, oxytocin, testosterone, and other hormone levels. The release of oxytocin may facilitate psychotherapy, whereas cortisol may increase stress and be counterproductive. MDMA administration is followed by a period of neurochemical recovery, when low serotonin levels are often accompanied by lethargy and depression. Regular usage can also lead to serotonergic neurotoxicity, memory problems, and other psychobiological problems.

Discussion: Proponents of MDMA-assisted therapy state that it should only be used for reactive disorders (such as PTSD) since it can exacerbate distress in those with a prior psychiatric history. Overall, many issues need to be considered when debating the relative benefits and dangers of using MDMA for psychotherapy.”

Author: Andrew C. Parrott

Summary

Historical Introduction and Brief Review of Recreational ECSTASY/MDMA

Alexander Shulgin described MDMA’s subjective effects as positive and life-affirming, and suggested that it might be useful as a drug-adjunct for psychotherapy. Some findings from these and subsequent therapeutic studies are noted below.

MDMA was categorized as an illegal drug in 1986, and therapeutic trials were stopped for a period of time. In the U.K., we used standardized mood assessment measures to empirically compare the subjective effects of MDMA with other recreational drugs, and found that it had generally intermediate effects between those of amphetamine and LSD.

Subsequent research has found that MDMA is associated with various deficits in memory and higher cognition, reduced immunocompetence, altered pain thresholds, depression and other forms of psychiatric distress, occupational problems, reduced happiness and greater everyday stress. MDMA causes structural changes to the serotonergic neurotransmitter system, and several neuroimaging studies have found evidence for “serotonin neurotoxicity” in abstinent MDMA users. There has been an active debate around the meaning of these changes.

In summary, there is a gradual accumulation of scientific evidence showing that recreational ecstasy/MDMA use can be damaging to humans. Furthermore, the deficits are not an artifact of other co-factors, and are mainly reflected by cumulative ecstasy/MDMA use, with other psychoactive drugs contributing to the adverse profiles.

Immediate Effects of MDMA

MDMA administration induces neurotransmitter activation across the main neural pathways, including serotonin, dopamine, noradrenaline, and others. This neurochemical activation can lead to a wide range of mood changes, including emotional excitation and sensitivity, as well as anxiety and fear-of-loss of thought control.

MDMA may stimulate the emergence of deep-seated thoughts and feelings, which can then be resolved via the professional guidance of the psychotherapist. However, if this is the main mode of operation for MDMA-assisted psychotherapy, then it does have potential dangers. One of the participants experienced the re-emergence of distressing anxiety, and needed an extended period of (non-drug) therapy afterwards to resolve the emergent problems. Another participant developed problems around appetite and eating.

Post-MDMA Recovery and Long-Term Consequences

Acute MDMA induces mood activation for 5-6 hours, followed by neurochemical depletion and feelings of anhedonia, lethargy, anger, and depression. The adverse recovery phenomena following MDMA have also been noted in controlled laboratory studies. These phenomena include depression, anxiety, insomnia, and appetite reductions, as well as increased aggression, greater susceptibility to pain, and reduced appetite and food intake.

Psychiatric Vulnerability and Stimulant Drugs

Greer and Tolbert warned against using MDMA with psychiatrically vulnerable individuals, and Rick Doblin recommended that MDMA-assisted psychotherapy be used with people suffering from Post Traumatic Stress Disorder (PTSD) and people facing terminal illness.

MDMA-assisted therapy is not safe for personal or recreational use, and repeated use tends to increase rather than reduce everyday stress. Regular ecstasy/MDMA users report more psychiatric symptoms, while quitting ecstasy/MDMA leads to improved psychiatric functioning in the majority of recreational users. Stimulant drug use can increase distress and heighten psychiatric problems, and these problems can be most pronounced in those with prior psychiatric susceptibilities.

Other Issues for Consideration

Greer and Tolbert (1986; 1990) suggested that one session with MDMA would be sufficient to engender enduring gains, but I believe that enduring changes can only occur through the psychotherapeutic element. Mithoefer et al. (2011) used MDMA-assisted psychotherapy to treat PTSD, but embedded the MDMA-assisted sessions into a longer series of drug-free sessions. The therapists were correct in all cases, and the clients showed significantly better gains after MDMA than placebo. The results show that there were no significant changes over time with the anxiety subscale, and that the depression subscale reduced over time in both groups, with the MDMA group showing slightly stronger gains.

There are other issues which need to be mentioned, such as the neurochemical model thought to underlie therapeutic improvement, the type of interactive therapy needed to embed any drug-induced experiences into enduring neurocognitive cognitive models, and potential legal issues if MDMA were to be used for medical purposes.

MDMA can induce aggression, including violence, and this is a negative effect that runs counter to the expected entactogenic actions of MDMA.

One external reviewer commented that patients with previously diagnosed depression become worse after an MDMA ‘session’ because it worked TOO well, acutely, and made them feel great or at least ‘normal’.

Final Overview

MDMA is a unique type of drug with positive acute effects, but it can stimulate the release of difficult feelings and memories, and the neurochemical recovery afterwards can be counter-productive, especially in psychiatrically vulnerable clients. Psychotherapists advocate MDMA-assisted therapy, but I believe that high-quality psychotherapy is always the most important aspect and that MDMA has far too many potentially damaging effects for safe general usage.

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