PTSD and Cannabis as Medicine

PTSD (post-traumatic stress disorder) is a specific form of trauma related disorder and is a serious mental illness. Affected individuals need trauma-specific psychotherapy¹. Medication may also be needed for support and stabilization during treatment.

The use of medical cannabis as a complementary treatment for mental illness is increasingly being addressed by research and science. Scientific studies are still at an early stage. But some empirical data gives first indications about the effect of medical cannabis².

Criteria for the prescription of medical cannabis

The "Cannabis as Medicine" law makes it possible for physicians of any specialty (except dentists and veterinarians) to prescribe cannabis as medicine on a narcotic prescription under certain conditions.

These conditions include the presence of a serious illness that is classified as treatment-resistant, for which no standard therapy is available, or for which the side effects of standard therapy are unacceptable. According to medical assessment, there must also be a chance that the symptoms will improve with medical cannabis.

Post-traumatic stress disorder briefly explained

Post-traumatic stress disorder (PTSD) can occur after a traumatic event. Such trauma occurs, for example, as a result of a serious accident, war experiences, natural disasters, experienced physical, psychological, and sexual violence, or severe emotional and/or physical neglect³.

PTSD: What are the causes?

Medical professionals do not assume that there are certain genetic or health conditions that favor the occurrence of PTSD. Rather, even people who were previously in the best of mental health can develop a stress disorder after a traumatic experience³.

When individuals repeatedly experience traumatic events over a long period of time (e.g., emotional neglect during childhood, sexual abuse), so-called complex post-traumatic stress disorder often manifests⁴.

In general, experiences added to persons by other people often lead to a more severe course than, for example, natural disasters. The patients experience a massive, permanent shaking of the self-image or world-image, which is reflected in the intensity of the disorder³.

In addition, supposed outsiders can also suffer from the experienced helplessness and the feeling of being at the mercy of others – for example, first responders or eyewitnesses.

PTSD Symptoms

PTSD symptoms usually do not appear immediately after the traumatic situation. In the first place, there are usually symptoms of shock. Affected persons feel numb and report the feeling of being on the sidelines as well as the sensation that everything seems unreal to them. This is a protective mechanism of the body and serves its own survival⁵.

After this acute stress reaction, the symptoms develop further and manifest themselves. PTSD symptoms can also appear months to years after the actual event⁵.

The main symptoms of post-traumatic stress disorder are⁵:

• Flashbacks: spontaneous memories of the trauma can be very distressing. For some, the memories come up only in fragments, while others feel like they have been taken back and relive the events. The triggers for flashbacks can be various stimuli, such as sounds, smells, places, people, etc. In addition to the flashbacks, there is usually massive anxiety as well as physical discomfort (e.g., racing heart, shortness of breath, sweating, dizziness, and trembling).

• Avoidance: Many affected people try to avoid the triggers because reliving the situations is psychologically very stressful. For example, if someone has experienced trauma as a result of a serious traffic accident, they may avoid driving and public transportation. The problem is that conscious avoidance has a counterproductive effect and increases anxiety and other symptoms.

• Vegetative overexcitation and anxiety: After experiencing a trauma, most people develop severe anxiety and are subsequently extremely jumpy. For health, this increased stress level is harmful. In addition, the permanent tension not infrequently leads to mild or severe irritability. Disproportionate outbursts of anger can also occur, as well as problems falling asleep or sleeping through the night.

• Loss of interest: the experiences made during the stressful events often cause people to withdraw from social life and also lose interest in it.

How is post-traumatic stress disorder diagnosed?

Post-traumatic stress disorder (PTSD) is diagnosed based on symptoms, and accurate diagnosis is necessary because different mental illnesses can have similar symptoms.

Affected individuals usually first consult their primary care physician. If PTSD is suspected, the patient is typically referred to a specialist (e.g., neurologist, psychiatrist, psychologist, trauma therapist).

After a detailed anamnesis interview, the doctors ask about the exact symptoms and possibly perform further tests^6,7:

• Clinician-Administered PTSD Scale (CAPS): This procedure is suitable for making a diagnosis of PTSD. After questions about the trauma have been asked, questionnaires are used to ask about the symptoms and their intensity and frequency. Finally, illnesses such as depression or addictions (e.g., abuse of drugs or alcohol) are queried.

• SKID-I test (structured clinical interview): This test is a guided interview. The therapist asks certain questions and then evaluates the answers according to a certain coding.

Diagnostic criteria for post-traumatic stress disorder

According to the International Statistical Classification of Diseases and Related Health Problems (ICD-10), the following criteria must be met for a diagnosis of PTSD⁸:

Patients

• Have been exposed to an extremely stressful event that would cause feelings of despair and helplessness in almost anyone,
• avoid situations, actions, as well as things they associate with the event,
• suffer from flashbacks, intrusions (reliving what happened while awake or asleep), anxiety, irritability, and angry outbursts

In addition, symptoms must occur within six months of the traumatizing event.

PTSD – treatment and therapy

For mental illnesses such as post-traumatic stress disorder (PTSD), comprehensive treatment that begins as early as possible is especially important.  Often, outpatient therapy is sufficient; hospitalization may be helpful under certain conditions, especially if the PTSD is severe or if there are other disorders such as severe depression, suicide risk or psychotic symptoms.

At the beginning of treatment, the affected person and, if possible, those close to them, are given extensive information about PTSD and the treatment options. A suitable treatment concept is then developed. The goal is to help sufferers control the unwanted memories as well as develop the ability to integrate the trauma into their life story, alleviate symptoms and restore quality of life.

Cognitive behavioral therapy is most commonly used, in which sufferers learn to notice and reevaluate their feelings, behaviors, and even what they have experienced. Psychotherapy, or more precisely psychodynamic therapy, can also be an option. Here, patients gradually come to terms with what they have experienced⁹.

Additional treatment methods

In addition to cognitive behavioral therapy and classical psychotherapy, the following methods may also be helpful^1,9,10:

• EMDR therapy (Eye Movement Desensitization and Reprocessing): One of the elements of EMDR therapy is guided eye movements. In this process, the affected person follows the fingers of the person providing therapy with their eyes while imagining the traumatic experience. This is said to help recall memories with less anxiety.

• Prolonged Exposure Therapy (PE): During therapy sessions, patients are imaginatively transported into the trauma they experienced and relive the unpleasant feelings, which is recorded on tape. Afterwards, they are asked to listen to the recording daily at home, which is intended to make the symptoms fade into the background.

• Cognitive Processing Therapy (CPT): This involves working on dysfunctional cognitions ("thinking errors") by using cognitive restructuring methods. Simply put, the goal is to uncover thinking patterns and change evaluations related to the trauma (e.g., feelings of guilt or shame).

• Narrative Exposure Therapy (NET): This method is concerned with the person's entire life and not with individual experiences. The goal is to work through unprocessed trauma with the help of exposure (confrontation).

• Brief Eclectic Psychotherapy for PTSD (BEPP): In this multimodal approach, different therapies are combined, or BEPP comprises 16 therapy sessions with the following central elements: Psychoeducation (education about the illness), exposure, writing tasks/work with mementos, meaning attribution/integration, farewell ritual.

In order to alleviate complaints such as feelings of anxiety, nervousness, irritability, etc., those affected can also become active themselves. There are various possibilities for this, such as learning relaxation techniques (e.g. autogenic training). Mindfulness training, the imagination techniques according to Reddemann, yoga, qi gong or tai chi can also help to alleviate the symptoms.

Medication support for PTSD

Whether medications such as antidepressants are a help in treating post-traumatic stress disorder is controversial. According to the guidelines of the German-speaking Society for Psychotraumatology (DeGPT), medications should not be used as the sole or primary therapy for PTSD because the effects are too small. Rather, psychotherapy or trauma therapy should always be in the center of attention. Only as a supportive measure, medications such as sertraline or paroextine are recommended in severe cases^1,9.

Cannabis in PTSD

Post-traumatic stress disorder is a mental illness for which trauma therapy must be a priority. Therapies with medications and also with medical cannabis can only be supportive.

Studies supporting cannabis for PTSD symptoms are still very preliminary. Nevertheless, many PTSD patients self-medicate with cannabis to relieve symptoms such as anxiety¹¹.

This approach is also supported by animal studies: When animals were given THC, they behaved less anxiously. In contrast, when the cannabinoid receptor CB1 is blocked, increased anxiety-related behavior is observed, indicating the role of cannabinoids in controlling anxiety and fear¹¹.

The amygdala, a region in the brain, is involved in processing threats and generating fear responses and is hyperactive in PTSD in response to trauma-related stimuli.  This makes it difficult to suppress attention and responses to these stimuli. In the amydala, the cannabinoid receptor CB1 is particularly abundant, and THC has been shown to affect the activity of this brain region. However, it is interesting to note that the effect of THC is dose-dependent: Low doses appear to decrease amygdala activity (anxiolytic), and high doses increase activity (anxiogenic)¹¹.

Other common PTSD symptoms include insomnia and nightmares. Small studies with THC (dronabinol and nabilone) have shown positive effects on these symptoms in PTSD patients^11,12,13.

Overall, further studies are needed to fully elucidate how cannabis can alleviate PTSD symptoms. However, preliminary and empirical data suggests that cannabis may indeed provide helpful relief for these patients.

How can Canify Clinics help?

Canify Clinics is here to help you get closer to your goal: We want to help you regain your quality of life. To do this, it is important to keep bureaucratic hurdles low and to adapt appointments and tasks to your everyday life. To make your path to cannabis therapy easier, we also offer online appointments, for example.

After you have registered on our portal without obligation, our doctors will check your documents and contact you promptly to discuss the next steps. If you are eligible for medical cannabis treatment, you will be scheduled for an appointment at one of our contracted practices or Canify Clinics. The follow-up appointments can take place from the comfort of your own home, and you can discuss everything important with your doctor via video conference. Only once per calendar year you will have to attend an appointment – we will be happy to help you prepare for this.

FAQ

How does PTSD manifest itself?

A traumatic event can have a lasting impact on your life, because PTSD sufferers relive the event over and over again in their thoughts and dreams. They often withdraw and avoid not only social contacts, but circumstances, places or activities associated with the experience. Physical symptoms manifest themselves in the form of tension, inner restlessness, nervousness, irritability, jumpiness, anxiety, panic, and sleep disturbances.

When do symptoms of PTSD appear?

Post-traumatic stress disorder is a mental disorder and is triggered by an experienced trauma. Shortly afterward, an acute stress reaction first becomes apparent. In order to be diagnosed with PTSD, the actual symptoms must appear within six months of the stressful trauma.

What can trigger PTSD?

Post-traumatic stress disorder can be traced to a severe and highly stressful event that leaves sufferers feeling helpless, defenseless, and at the mercy of others and experiencing great anxiety. Possible triggers can include wars, terrorist attacks, torture, escape, assault, emotional violence, severe neglect, or individual experiences of violence such as sexual abuse and rape.

What happens if PTSD is not treated?

In most cases, post-traumatic stress disorder has a good chance of recovery if appropriate therapies are initiated in a timely manner. If no targeted treatment is given, it can develop into a chronic course. There is then a risk that other mental illnesses (e.g. depression, anxiety or addiction disorders) will develop.

Disclaimer and legal information

This article is for informational purposes only and is not a substitute for medical advice from a doctor. The content is not intended to motivate self-diagnosis or self-treatment, nor to tempt people to change their own medical treatment. Canify Clinics does not make any recommendations or promote any diagnostic methods or treatments. If you wish to change your treatment, this should always be discussed with a doctor. Furthermore, Canify Clinics cannot guarantee the accuracy, timeliness and balance of the content. Therefore, neither the authors of the texts nor Canify Clinics accept any liability for damages resulting from the independent use of the information described here.

References

1.     Schäfer, I., et al. POSTTRAUMATISCHE BELASTUNGSSTÖRUNG. SPRINGER VERLAG, BERLIN, (2019).

2.     Bilbao, A. & Spanagel, R. Medical cannabinoids: a pharmacology-based systematic review and meta-analysis for all relevant medical indications. BMC Med 20, (2022).

3. Charité Universitätsmedizin Berlin; “Posttraumatische Belastungsstörungen (PTBS): Klinik für Psychiatrie und Psychotherapie | CBF - Charité”

4.     Deutschsprachige Gesellschaft für Psychotraumatologie, DeGPT, „Komplexe posttraumatische Belastungsstörung“

5.     Ärztliches Zentrum für Qualität in der Medizin (ÄZQ), Berlin, patienten-information.de, „Posttraumatische Belastungsstörung – immer wieder schlimme Erinnerungen“

6.     ZEP Zentrum für Psychotraumatologie Hamburg, „PTBS Diagnostik“

7. Universitätsklinikum Ulm, „Clinician-Administered PTSD Scale (CAPS)“

8.     Dreßing, H. R. & Foerster, K. Diagnostic Criteria of PTSD in ICD10, ICD-11 and DSM 5: Relevance for expert opinion. Fortschritte der Neurologie Psychiatrie 89, 578–592 (2021).

9.     Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), gesundheitsinformationen.de, „Psychotherapie und ergänzende Behandlungen bei einer posttraumatischen Belastungsstörung“

10.  Neurologen und Psychiater im Netz, Prof. Dr. med Ulrich Schnyder, „Posttraumatische Belastungsstörung – Therapie“

11.  Rabinak, C. A. et al. Cannabinoid modulation of corticolimbic activation to threat in trauma-exposed adults: a preliminary study HHS Public Access. Psychopharmacology (Berl) 237, 1813–1826 (2020).

12.  Jetly, R., Heber, A., Fraser, G. & Boisvert, D. The efficacy of nabilone, a synthetic cannabinoid, in the treatment of PTSD-associated nightmares: A preliminary randomized, double-blind, placebo-controlled cross-over design study. Psychoneuroendocrinology 51, 585–588 (2015).

13.  Cameron, C., Watson, D. & Robinson, J. Use of a synthetic cannabinoid in a correctional population for posttraumatic stress disorder-related insomnia and nightmares, chronic pain, harm reduction, and other indications: a retrospective evaluation. J Clin Psychopharmacol 34, 559–564 (2014).