Journal of the California Cannabis Research Medical
Cannabis Eases Post Traumatic
By Tod Mikuriya, MD
William Woodward, MD, of the American Medical Association,
testifying before Congress in 1937 against the Prohibition of cannabis,
paraphrased a French author (F. Pascal, 1934) to the effect that “Indian
hemp has remarkable properties in revealing the subconscious.” A
Congressman asked, “Are there any substitutes for that latter
psychological use?” Woodward replied, “I know of none.
That use, by the way, was recognized by John Stuart Mill in his work
on psychology, where he referred to the ability of Cannabis or Indian
hemp to revive old memories —and psychoanalysis depends on revivivification
of hidden memories.”
For including that reference to Mill (1867) in the list I have been
compiling of conditions amenable to treatment by cannabis, I was ridiculed
by Drug Czar Barry McCaffrey in 1996. I stand by its inclusion, of
course, and in the 10 years since California physicians have been approving
cannabis use by patients, I have found myself appreciating and confirming
Mill’s insight with every report that cannabis has eased symptoms
of post-traumatic stress disorder.
PTSD As a Dissociative Disorder
PTSD—a chronic condition involving horrific memories that cannot
be erased—is a dissociative identity disorder. The victims’s
psyche is fragmented in response to contradictory inputs that cannot
Dissociative identity disorders are expressed in bizarre or inappropriate
behaviors with intense sadness, fear, and anger. Repression or “forgetting” of
the experiences may develop as a coping mechanism.
When traumatic or abusive experiences cannot be integrated into normal
consciousness —as in the case of the Jekyl-Hyde behaviors of
abusive parents or caregivers— creation of separate personalities
or identities may occur.
For example, the woman who was molested by a family member may have
both superfically-compliant and repressed-raging identities. The persona
that’s presented to the world can be swept away when a stimulus
calls forth the overwhelming rage.
Such fragmenting of the individual personality causes tremendous stress.
The psyche is incomplete because of repression and denial. The person
tries to appear normal and logical but in fact is in turmoil, angry
and depressed. The inability to deal directly with emotional issues
results in ongoing splitting and compartmentalization of the personality —and
in extreme cases, multiple personalities, hysterical fugue (a separate
state of consciousness that the individual may not recall), blindness,
paralysis, and other functional disruptions.
In 1994 the term “Multiple Personality Disorder” was replaced
with the more widely applicable “Dissociative Identity Disorder.” As
an article (by Foote et al) and editorial (Spiegel) in the April 2006
American Journal of Psychiatry attest, it is only relatively recently
that PTSD has been characterized as a dissociative disorder. [continued
A 52-year-old retired executive secretary brought her 20-year-old
daughter along to her follow-up interview two years after starting
cannabis therapy. During her initial visit she had not disclosed
fully the causality of her chronic depression with symptoms of
PTSD (nightmares, chronic insomnia, dissociative episodes, rage).
She was experiencing loss of emotional control with crisis psychiatric
interventions. Hypervigilance characterized her presentation;
she described herself as being “all clenched up.”
On follow-up she reported being able to recover and process repressed
memories of sexual abuse from age five to 15 by her father (a
preacher) and having been beaten by her enraged mother. She reported
diminution and cessation of dissociative reactions to the painful
memories. This permitted her to process and resolve —or come
to an accord with— these unthinkable memories. Her continuing
psychotherapy focused on these issues. She no longer experienced
episodes of loss of control. She was able to relax her hypervigilance.
Her self-esteem was significantly improved and she seemed happy
Her daughter confirmed that her mother was less irritable and more
emotionally available since starting cannabis therapy. Both described
improvement in their relationship.
A 55-year-old disabled male veteran had been a naval air crewman
on patrol during the Vietnam war. A P2V turbo-prop engine failed
to reverse properly on landing. A propeller broke loose, pierced
the fuselage, and instantly killed his crew mate who was two
feet away. He brought a large binder of documentation of the
His PTSD was expressed primarily through a haunting, recurrent flashback nightmares
that replayed the traumatic event. Attendant were the feelings of being emotionally
overwhelmed. Sleep deficit was a salient aggravating factor for increasing vulnerability.
Cannabis restored sleep and controlled nightmares. Depression and irritability
had been eased.
Easement by Cannabis
Approximately eight percent of the >9,000 Californians whose cannabis
use I have monitored presented with PTSD (309.81) as a primary diagnosis.
Many of them are Vietnam veterans whose chronic depression, insomnia,
and accompanying irritability cannot be relieved by conventional psychotherapeutics
and is worsened by alcohol. For many of these veterans, chronic pain
from old physical injury compounds problems with narcotic dependence
and side effects of opioids.
Survivors of childhood abuse and other traumatic experiences form a
second group manifesting the same symptoms —loss of control and
recurrent episodes of anxiety, depression, panic attacks and mood swings,
chronic sleep deficit and nightmares.
The brief case reports in the box at the right of this page, unique
though the subjects may be, typify two different forms that PTSD takes,
both of which are eased by cannabis. The recurrent nightmares from
the vet’s traumatic episode took on a life of their own, causing
nocturnal turmoil and dread. The repressed memories of the sexually
abused and beaten woman were symptoms of a fragmented, dissociative
response to the disorder.
Easement by cannabis helped both —the vet by toning down his
reaction to the nightmares and restoration of his sleep, the woman
by modulating her emotional reactivity and permitting her to process
and integrate the experience and give up the fragmented, dissociative
defense mechanisms, which in due course she no longer needed.
Repression and suppression are defense mechanisms that break down when the
victim is fatigued and/or hurting and subjected to triggering stimuli. With
cannabis, vegetative functions necessary for recovery, growth and repair are
Cannabis relieves pain, enables sleep, normalizes gastrointestinal function
and restores peristalsis. Fortified by improved digestion and adequate rest,
the patient can resist being overwhelmed by triggering stimuli. There is no
other psychotherapeutic drug with these synergistic and complementary effects.
Practical Treatment Goals
In treating PTSD, psychotherapy should focus on improving how the
patient deals with resurgent symptoms rather than revisitation
of the events.
Decreasing vulnerability to symptoms and restoring control to the
individual take priority over insight as treatment goals. Revisiting
events without closure and support is not useful but prolongs and
exacerbates pain and fear of loss of control. To repeat: cathartic
the traumatic experience(s) without support and closure is anti-therapeutic
and can exacerbate symptoms.
Physical pain, fatigue, and sleep deficit are symptoms that can be
ameliorated. Restorative exercise and diet are requisite components
of treatment of PTSD and depression. Cannabis does not leave the
patient too immobile to exercise, as do some analgesics, sedatives
etc. Regular aerobic exercise (where injury does not interfere) relieves
tension and restores control through kinesthetic involvement. Exercise
also internalizes the locus of control and diminishes drug-seeking
to manage emotional response.
The importance of sound sleep
PTSD often involves irritability and inability to concentrate, which
is aggravated by sleep deficit. Cannabis use enhances the quality
of sleep through modulation of emotional reactivity. It eases the
triggered flashbacks and accompanying emotional reactions, including
The importance of restoring circadian rhythm of sleep cannot be overestimated
in the management of PTSD. Avoidance of alcohol is important in large
part because of the adverse effects on sleep. The short-lived relaxation
and relief provided by alcohol are replaced by withdrawal symptoms
at night, causing anxiety and the worsening of musculoskeletal pain.
Evening oral cannabis may be a useful substitute for alcohol. With
proper dosage, the quality and length of sleep can be improved without
morning dullness or hangover. For naïve patients, use of oral
cannabis should be gradually titrated upward in a supportive setting;
this is the key to avoiding unwanted mental side effects.
I recommend the protocol J. Russell Reynolds M.D., commended to Queen
dose should be given in minimum quantity, repeated in not less than four to
six hours, and gradually increased by one drop every third or fourth day, until
either relief is obtained, or the drug is proved, in such case to be useless.
With these precautions I have never met with any toxic effects, and have rarely
failed to find, after a comparatively short time, either the value or the uselessness
of the drug.”
The advantage of oral over inhaled cannabis for sleep is duration of effect;
a disadvantage is the time of onset (45-60 minutes). When there is severe recurrent
insomnia with frequent awakening it is possible to medicate with inhaled cannabis
and return to sleep. An unfortunate result of cannabis prohibition is that
researchers and plant breeders have not been able to develop strains in which
sedative components of the plant predominate.
Modulation, Not Extinction
Although it is now widely accepted that cannabinoids help extinguish
painful memories, my clinical experience suggests that “extinguish” is
Cannabis modulates emotional reactivity, enabling people to integrate
painful memories —to look at them and begin to deal with them,
instead of suppressing them until a stimulus calls them forth with
The modulation of emotional response relieves the flooding of negative
affect. The skeletal and smooth muscle relaxation decreases the release
of corticosteroids and escalating “fight-or-flight” agitation.
The modulation of mood prevents or significantly decreases the symptoms
of anxiety attacks, mood swings, and insomnia.
While decreasing the intensity of affectual response, cannabis increases
introspection as evidenced by the slowing of the EEG after initial
stimulation. Unique anti-depressive effects are experienced immediately
with an alteration in cognition. Obsessive and pressured thinking give
way to introspective free associations (given relaxed circumstances).
Emotional reactivity is calmed, worries become less pressing.
Used on a continuing basis, cannabis can hold depressive symptoms at
bay. Agitated depression appears to respond to the anxiolytic component
of the drug. Social withdrawal and emotional shutting down are reversed.
The short-term memory loss induced by cannabis that may be undesirable
in other contexts is therapeutic in controlling obsessive ideation,
amplified anxiety and fear of loss of control ignited by the triggering
Easement Effects of Cannabis
In treating PTSD, cannabis provides control and amelioration of chronic
stressors without adverse side effects. Mainstream medicine treats
PTSD symptoms such as hyperalertness, insomnia, and nightmares with
an array of SSRI and tricyclic anti-depressants, sedatives, analgesics,
muscle relaxants, etc., all of which provide inadequate relief and
have side effects that soon become problematic. Sedatives, both prescribed
and over-the-counter, when used chronically, commonly cause hangovers,
dullness, sedation, constipation, weight gain, and depression. See
chart at right.
Cannabis is a unique psychotropic immunomodulator which can best be
categorized as an “easement.” Modulating the overwhelming
flood of negative affect in PTSD is analogous to the release of specific
tension, a process of “unclenching” or release. As when
a physical spasm is relieved, there is a perception of “wholeness” or
integration of the afflicted system with the self. For some, this perceptual
perspective is changed in other ways such as distancing (separating
the reaction from the stimulus, which can involve either lessening
the reaction, as with modulation, or repressing/suppressing the memory;
walling it off; forgetting).
The modulation of emotional response relieves
the flooding of negative affect. The skeletal and smooth muscle relaxation
decreases the sympathetic
nervous reactivity and kindling component of agitation. Fight/flight
responses and anger symptoms are significantly ameliorated. The fear
of loss of control diminishes as episodes of agitation and feeling
overwhelmed are lessened. Experiences of control then come to prevail.
Thinking is freed from attachment to the past and permitted to fix
on the present and future. Instead of being transfixed by nightmares,
the sufferer is freed to realize dreams.
Based on both safety and efficacy, cannabis should be considered first
in the treatment of post-traumatic stress disorder. As part of a restorative
program with exercise, diet, and psychotherapy, it should be substituted
for “mainstream” anti-depressants, sedatives, muscle relaxants,
The Toxic Alternatives
Commonly prescribed medications for PTSD as listed in “Postraumatic
Stress Disorder Among Military Returnees From Afghanistan and Iraq,” by
Matthew J. Friedman, MD, PhD, in the April 2006 American Journal of
Paroxetine, Sertraline, Pluoxetine, Citalopram, Fluvoxamine
May produce insomnia, restlessness, nausea, decreased appetite, daytime
sedation, nervousness, and anxiety, sexual dysfunction, decreased libido,
delayed orgasm or anorgasmia. Clincically significant interactions
for people prescribed monoamine oxidase inhibitors (MAOIs). Significant
interactions with hepatic enzymes produce other drug interactions.
Concern about increased suicide risk in children and adolescents.
Other second-generation antidepressants:
Trazadone may be too sedating, may produce rare priapism. Velafaxine may exacerbate hypertension. Buproprion may exacerbate seizure disoder.
Mirtrazepine may cause sedation.
Risk of hypertensive crisis; patients required to follow a strict dietary
regime. Contraindicated in combination with most other antidepressants,
CNS stimulants, and decongestants. Contraindicated in patients with
alcohol/substance abuse/dependence. May produce insomnia, hypotension,
anticholinergic side effects, and liver toxicity.
Imipramine, Amitriptyline, Desipramine
Anticholinergic side effects (dry mouth, rapid pulse, blurred vision,
constipation). May produce ventricular arrhythmias. May produce orthostatic
hypotension, sedation, or arousal.
Prazosin, Propranolol, Conidine, Guanfacine
May produce hypotension, brachycardia (slow heartbeat), depressive
symptoms, psychotomor slowing or bronchospasm.
Carbamazepine may cause neurological symptoms, ataxia,
drowsiness, low sodium level, leukopenia. Valproate may cause gastrointestinal
problems, sedation, tremor and thrombocytopenia (low platelet levels
in blood). It is teratogenic (induces mutations, should not be used
during pregnancy). Gabapentin may cause sedation
and ataxia (difficulty forming sentences). Lamotrigine may
cause Stevens-Johnson syndrome, rash, fatigue. Toprimate may cause
glaucoma, sedation, dizziness,
Risperidone, Olanzapine, Quetiapine
May cause weight gain. Risk of type 2 diabetes with olanzapine
Cannabis as a treatment for PTSD provides effective control and relief
of chronic stressors. Its side-effect profile seems especially benign
when contrasted with those of the prevailing mainstream treatments.--T.H.M.