Post-Traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) is one reason many patients seek medical cannabis due to its ability to relieve stress and insomnia.

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What is Post-Traumatic Stress Disorder (PTSD)?

PTSD is when an extremely traumatic, stressful, distressing, or frightening experience or series of experiences is relived. Nightmares, flashbacks of the traumatic event or events, feelings of isolation, withdrawal, guilt, and irritability are common signs and symptoms. PTSD is often, but not always, grouped with anxiety disorders, as they share many common signs and symptoms. Depression is also often comorbid with PTSD. Those who have faced a series of traumatic events or one traumatic event over a long period are more likely to be diagnosed with complex PTSD (cPTSD). PTSD is usually related to a single, briefer traumatic event.

Approximately 12 million adults in the U.S. have PTSD during a given year. An estimated 6% of adults in the U.S. will develop PTSD during their lifetime. Women are more likely to develop PTSD during their lifetime compared to men. This could be due to several different reasons, such as the type of trauma, differences in how trauma is processed, and men’s symptoms not typically following the diagnostic criteria for PTSD as it is currently defined.

PTSD is often put under the umbrella of “anxiety disorders,” although nowadays, it is often given its own separate section in some mental health manuals. There are many similarities with anxiety disorders in that there are abnormal levels of norepinephrine and cortisol in the blood compared to those without PTSD (normally low levels of both).

Those with chronic PTSD have a smaller hippocampus. There also seems to be an abnormality in the hypothalamic-pituitary-adrenal (HPA) axis. Exposure to traumatic events can increase the likelihood of suffering from PTSD, and the HPA axis that coordinates the stress response activates the LC-noradrenergic system, which results in an over-consolidation of specific memories. Those with PTSD also have chronically low serotonin and serotonin receptor expression levels.

Brief Summary of Current Treatments

Non-medication first-line treatments include psychological therapies such as trauma-focused cognitive behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR). Following a healthy diet, engaging in exercise and practicing good sleep hygiene is also highly recommended. Relaxation techniques that are also recommended include focused breathing, meditation and yoga.

When it comes to prescription medications, antidepressants like paroxetine, sertraline, escitalopram, mirtazapine, amitriptyline or phenelzine are common first-line treatments.

While antidepressants may be effective for PTSD, there do seem to be some marked differences in terms of how biochemical changes in the brain and body occur when compared to depression. So, while PTSD can share similar symptoms with anxiety and depression (and could well be a comorbid condition), there are differences between the conditions and how they are treated.

Other medications prescribed for PTSD include anticonvulsants like pregabalin and benzodiazepines like diazepam (Valium). These have varying levels of efficacy, and those with PTSD should avoid long-term use of benzodiazepines.

How Might Medical Cannabis Help?

Current prescription medications have side effects that can sometimes worsen symptoms of PTSD. These include:

• Feeling agitated
• Nausea/vomiting
• Dizziness
• Loss of balance
• Insomnia
• Headaches
• GI upset
• Uncontrollable sweating
• Shakes or tremors
• Addiction (benzodiazepines)
• In some cases, an increased chance of suicide

There are several possible benefits of cannabis over prescription medications, such as:

1. Antidepressants can take several weeks to take effect. Many people have to try several different antidepressants before finding one that is effective. Medical cannabis, meanwhile, has same-day effects, allowing patients to determine if medical cannabis is suitable for themselves.
2. Fewer negative side effects: Many current prescription medications may actually cause or worsen side effects the patient is seeking relief from in the first place.
3. When it comes to prescription benzodiazepines for PTSD, there is little evidence for their efficacy. Worse still, benzodiazepines may be contraindicatedfor PTSD, yet are still prescribed: “Benzodiazepines might be effective if they selectively inhibited the stress and anxiety centers of the brain that are often hyperactive in PTSD,” researcher Jeffrey Guina, MD, Wright State University, Dayton, Ohio, said in a statement. “Instead, they indiscriminately target the entire brain–including areas that are already hypoactive in PTSD, such as the cognitive and memory centers.”
4. Cannabis contains many anti-inflammatory and stress-busting compounds (cannabinoids, terpenes, flavonoids) that can help alleviate anxiety and aid relaxation.
5. Medical cannabis can help reduce or replace intake of several different classes of drugs, including antidepressants, anxiolytics, anticonvulsants, benzodiazepines and other sedatives and opioids: “Pain medication was the most prevalent prescription drug substituted with CaM [cannabis as medicine], followed by antidepressants and arthritis medication.”
6. Those who experience trauma in childhood demonstrate decreased levels of endocannabinoid ligands and receptors. While those who experience trauma in adulthood demonstrate decreased levels of endocannabinoid ligands, but increased levels of cannabinoid receptors.

Cannabinoids

• Tetrahydrocannabinol (THC) = appetite stimulant, pain-relieving, sedative and may help reduce the intensity and frequency of nightmares
• Cannabidiol (CBD) = anti-inflammatory, anxiolytic (anti-anxiety) and can help buffer some of the psychotropic effects of THC
• Cannabigerol (CBG) = may enhance pleasure and motivation and regulate sleep and appetite
• Cannabinol (CBN) = has sedative effects that may help manage insomnia

Cannabinoid Ratios

CBD-rich formulas may be of particular interest for PTSD sufferers, although some may be able to tolerate more THC compared to those who suffer from anxiety alone. Some potentially useful THC:CBD ratios could include:

• 1:3
• 1:2
• 1:1

Terpenes and Terpenoids

• Limonene
• Linalool
• Bisabolol
• Myrcene
• Beta-caryophyllene
• Humulene

Flavonoids

Some flavonoids that could be useful for managing PTSD symptoms due to their anti-inflammatory and stress-busting effects include:

• Cannflavin A, B and C
• Quercetin
• Kaempferol

Effective Ways of Taking Medical Cannabis for Post-Traumatic Stress Disorder

Routes of Administration

• Inhalation (combustion, vaping, inhalers)
• Sublingual
• Ingestion

Special Formulations

Cannabis products with a mixture of THC, CBD, CBN, linalool, myrcene, limonene and beta-caryophyllene may be useful. Some cannabis cultivars (often called “strains”) that may have such a profile include:

• Cannatonic
• Blue Dream
• Northern Lights
• Purple Kush
• Harlequin

However, what works for one person may not work for another due to individual differences in their endocannabinoid system (ECS).

Dosing Methods

• Inhalation (combustion, vaping, inhalers) is ideal for immediate effects.
• Tinctures can have potent, long-lasting effects, and it is relatively easy to take a measured dose.
• Edibles carry potent, long-lasting effects.
• Those who have been diagnosed with another anxiety disorder may want to avoid consuming too much THC to decrease the likelihood of an anxiety or panic attack.

What are the Pros and Cons of Taking Medical Cannabis for Post-Traumatic Stress Disorder?

Potential Pros

• Terpenes such as linalool, beta-caryophyllene and limonene may help beat stress and anxiety.
• CBD may improve regional cerebral blood flow (rCBF) in the brain, helping reduce anxiety and increasing the amount of important hormones and nutrients moving through the brain.
• May help keep the mind off of reliving traumatic experiences.
• Terpenes like pinene can help prevent hyperventilation.
• May help promote sleep and a night’s rest, with fewer sleep disturbances and nightmares.
• Unfortunately, sometimes drugs that have no proven efficacy for PTSD (e.g., benzodiazepines, antipsychotics) are still prescribed. Phytocannabinoids (plant cannabinoids) like THC and CBD may help replace these substances.

Potential Cons

• Take care with using THC–too high a dose may increase anxiety and heart rate throughout the “high.”
• Can cause an initial increase in heart rate.
• Can increase feelings of depersonalization.

Useful Anecdotal Information

• Veteran Mike Whiter Explains How Cannabis Can Help Veterans With PTSD | NowThis
• Medical Marijuana: Pot for Veterans and PTSD | CBS News
• Veterans and PTSD: is Medical Marijuana the Answer? | The Denver Channel
• Matt Hill, PhD – Your Brain on PTSD: The Impact of Cannabis

Scientific Data Overview and Studies

• Total Studies = 51
• Positive Studies = 40
• Inconclusive Studies = 5
• Negative Studies = 6
• 32 Meta-Analyses (25 positive, 4 inconclusive, 3 negative); 10 Animal Studies (7 positive, 1 inconclusive, 2 negative); 3 Double-Blind Human Trials (2 positive, 1 negative); 6 Human Trials (all positive)
• 13 studies include CBD (11 positive, 2 inconclusive); 9 studies include THC (5 positive, 1 inconclusive, 3 negative)
• No. of Leafwell Patients (2021) = 10,955
• Possible Overall Efficacy: Moderate to High

Quotes from Studies

“PTSD diagnosis and symptom severity were assessed in structured clinical interviews employing the Posttraumatic Diagnostic Scale (PDS). A significant group difference was observed for OEA [oleoylethanolamide], with PTSD patients showing reduced hair concentrations. Regression analyses further revealed strong negative relationships between all investigated N-acyl-ethanolamides and symptom severity of PTSD. The observed reductions in endocannabinoids might account for the increased inflammatory state as well as for the failure to extinguish fear memories observed in PTSD. Our findings add to the accumulating evidence suggesting the endocannabinoid system as a target for pharmacological enhancement of exposure-based psychotherapy for PTSD.”

Wilker, Sarah et al. ‘Endocannabinoid concentrations in hair are associated with PTSD symptom severity’. Psychoneuroendocrinology. 2016 May;67:198-206. doi: 10.1016/j.psyneuen.2016.02.010. Epub 2016 Feb 12.

“In this small sample [10 participants] NAB provided significant relief for military personnel with PTSD, indicating that it shows promise as a clinically-relevant treatment for patients with nightmares and a history of non-response to traditional therapies. These findings need to be replicated in a larger cohort. There is a need for further exploration of the effect of nabilone on other symptoms of PTSD such as re-experiencing, hypervigilance and insomnia.”

Jetly, Rakesh et al. ‘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, 2015 Jan;51:585-8. doi: 10.1016/j.psyneuen.2014.11.002. Epub 2014 Nov 8.

“The present study is the first randomized placebo-controlled trial of smoked cannabis for PTSD. All treatment groups, including placebo, showed good tolerability and significant improvements in PTSD symptoms during three weeks of treatment, but no active treatment statistically outperformed placebo in this brief, preliminary trial. Additional well-controlled and adequately powered studies with cannabis suitable for FDA drug development are needed to determine whether smoked cannabis improves symptoms of PTSD.”

Bonn-Miller, Marcel O. et al., ‘The short-term impact of 3 smoked cannabis preparations versus placebo on PTSD symptoms: A randomized cross-over clinical trial’

PLoS One, 2021 Mar 17;16(3):e0246990. doi: 10.1371/journal.pone.0246990. eCollection 2021.

Conclusion

There is some good-quality evidence that medical cannabis helps improve several quality of life (QOL) metrics associated with PTSD, such as reduced sleep and appetite, anxiety, fatigue and lack of motivation. However, it is worth noting that there are some studies (including human trials) that display inconclusive or negative results, some of which may be associated with the psychoactive effects of THC and possible anxiety-comorbidity. It is also worth noting that many studies have low sample sizes, meaning that definitive conclusions cannot be drawn until we have larger data sets. More research is needed to fully grasp cannabis’ efficacy in this area.

Related Articles

• How Medical Marijuana and CBD Affect Post-Traumatic Stress Disorder (PTSD)
• 5 Best Marijuana Strains for PTSD
• Cannabis for Veterans and PTSD: A Conversation With Balanced Veterans
• Why Is Cannabis So Effective for PTSD?
• Leafwell Highlights PTSD Awareness Day

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