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Cannabinoids PTSD, ADHD and beyond

Cannabinoids PTSD, ADHD and beyond. Some Thoughts on Why Cannabinoids Work for PTSD, ADHD, etc. David Bearman,M.D. Fourth National Conference on Cannabis Therapeutics. There’s a lot to learn.

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Cannabinoids PTSD, ADHD and beyond

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  1. Cannabinoids PTSD, ADHD and beyond Some Thoughts on Why Cannabinoids Work for PTSD, ADHD, etc. David Bearman,M.D. Fourth National Conference on Cannabis Therapeutics

  2. There’s a lot to learn • “Doctors prescribe medicines of which they know little,to cure diseases of which they know less,in human beings of whom they know nothing” Voltaire 1694-1778

  3. Patient Endorsements • “If it wasn’t for marijuana I'd be out shooting people.” • “With cannabis I am able to sleep, and don’t have the nightmares.” • “When I use marijuana I am able to deal with people without being so angry and abrupt.”

  4. More Patient Testimonials • “Marijuana made it so I could achieve. I realized that I wasn’t stupid.” • “My son,who has ADD, initially used marijuana recreationally.He soon discovered he could do his homework much better with marijuana.” • In my experience at Zona Seca teenagers referred for marijuana use either have a learning disability,come from a dysfunctional family or both.

  5. Labels For PTSD • WWI Shell Shock • WWII Battle Fatigue • Vietnam PTSD

  6. PTSD Symptoms • Hyper-alertness • Nightmares • Flashbacks • Quick to anger • Anxiety • Panic Attacks • Persistent Frightening Thoughts

  7. Causes of PTSD • War • Torture • Rape • Molestation • Domestic Violence • Serious Accident • Natural Disaster • Being raised in a dysfunctional family

  8. Soldiers

  9. Rape Picture

  10. Childhood ptsd symptoms

  11. PTSD,ADHD and Associated Conditions

  12. Triggers • Things Which Remind The Person of The Event • Certain Places,Situations,Smells • Movies or TV about War(ie Iraq) • Normal Stuff-backfire,someone getting too close physically • Large Body Buffer Zone

  13. Conventional PTSD Treatment • Medication • Emotional Counseling • Combination of the Two

  14. Common Medications • Lexapro • Prozak • Paxil • Effexor

  15. Therapeutic Effects Vs.Side Effects • Therapeutic Effect-Make the patient more manageable(e.g.increase concentration, decrease anxiety , increase comfort level around others, manage anger better, more patience with life’s inanity and insanity • Side Effects-somnolence, decreased libido, feeling of depersonalization or being drugged

  16. What’s Going On? • We need to know about: • Dopamine • Limbic system • Retrograde inhibition • anandamide

  17. Words-Its all about words • Dopamine=neurotransmitter • Limbic System=part of midbrain related to emotion,memory, and motivation. • Anandamide-one of 2 endocannabinoids • Retrograde stimulation aka neuronal inhibition-decreases rate and amount of neurotransmission

  18. Dopaminergic System • “Converging evidence has implicated abnormalities of dopamine neurotransmission to the pathology of attention deficit hyperactivity disorder (ADHD).” Dopaminergic system genes in ADHD: toward a biological hypothesis. Neuropsychopharmacology 202 Oct; 27(4):607-19. Kirley A. Hawi Z, Daly G, McCarron M, Mullins C, Millar N, Waldman I, Fitzgerald M, Gill M. • “Numerous studies have shown the importance of the mesocorticolimbic dopamine system in the pathophysiology of attention deficit/hyperactivity disorder. However, there has been inconsistency in the findings of those studies. Varied and sometimes contradictory interpretation has been made on the basis of similar results.” Ohno M. Congenit. Anom. Kyoto. 2003 Jun; 43(2): 114-22.

  19. In Plainer English • It’s a dysfunctional dopamine system • It’s the midbrain(eg limbic system) • It’s other complicated stuff researchers are speculating about(eg serotin,a combination of too much and too little dopamine)

  20. What Affects the Dopamine System ? • It is emotional trauma? We see that is cause of PTSD • At least 30 to 40% of my ADHD patients have had emotionally traumatic events in childhood(e.g.emotional,physical or sexual abuse, separation from mother, other stressors). Some ADHD patients have had adult trauma such as Viet Nam. ADHD has a genetic component. I’ve not seen that with PTSD

  21. A Dopaminergic Model of PTSD low dopamine activity can cause low stimulation of inhibitory autoreceptors .This leads to high activity in the nucleus accumbens and other subcortical sites,which may result in dysregulated motor and impulse control. Grace 2000

  22. Bearman‘s Guess • Over load the midbrain (Limbic Sys) • Overload Amygdala • Limbic System is Important in Controlling our Emotions • Triggers, trigger stimulus Overload of Midbrain and Cortex

  23. Synapse

  24. Normal # Dopamine Transporters

  25. More Dopamine Transporters Means a Need for More Dopamine

  26. How Stimulants Work to treat ADHD THEY BLOCK DOPAMINE REUPTAKE this increases synaptic levels of dopamine. Which increases the stimulation of impulse regulating auto receptors.This decreases internal and external sensory input .

  27. Ritalin & Dexedrine in ADHD Act by binding to dopamine transporter.This blocks reuptake of catecholeamines.In this way stimulants compensate for catecholeamine deficiency in ADHD.

  28. Stimulant Controversy “Despite progress in the assessment, diagnosis and treatment of ADHD,this disorder and its treatment have remained controversial especially the use of psycho stimulants for both short- and long-term treatment” 1998 NIH Consensus Statement

  29. Anandamide & ADHD Blocking the inactivation of anandamide could correct ADHD. Piomelli et al. Journal of Neuroscience, May 2000

  30. Jefferson & Hemp • Hemp is of first necessity to the commerce and marine,in other words to the wealth and protection of the country Thomas Jefferson,author of the Constitution,3rd President of the United States and founder of the University of Virginia

  31. Cannabinoids & PTSD Endogenous and exogenous cannabinoids increase the availability of dopamine.This addresses the problem of too little dopamine and/or too many dopamine transporters.

  32. Where are those CB 1 Receptors? HIGHEST CONCENTRATIONS: HYPPOCAMPYL FORMATION- learning memory SUBSTANTIA NIGRA & GLOBUS PALLIDUS-coordinate movement LIMBIC AREA-emotion,motivation,higher intellectual function

  33. Limbic System Limbic system is important in emotion and motivation.Especially those related to survival-fear,anger,sex and pleasure. Two important Limbic system structures (1) amygdala,important in emotions and feelings (2) hippocampus ,involved in memory.

  34. Amygdala & Hippocampus Amygdala-emotion Hippocampus-memory

  35. Prefrontal cortex plays a role

  36. Frontal Cortex & ADHD • Frontal Cortex Mainly Involved in Executive Function • problem solving • attention • reasoning • planning

  37. Basal Ganglia • The basal ganglia are responsible for regulating movement. • They are connected with the frontal lobe • Imaging data suggests problems in the circuits between the prefrontal cortex and basal ganglia are important in ADHD mechanisms • adhd ORG.NZ. The Neurobiology of ADHD

  38. Dysfunctional Prefrontal-Basal Ganglia Circuits Demonstrated by Functional Imaging • Imaging allows researchers to see the brain at work • SPECT and FEMRI imaging found dysfunction of 3 circuits involving the frontal lobe and basal ganglia • “The dopaminergic system in attention deficit hyperactivity disorder” Congenit Anom. Kyoto.2003 June, 43(2):114-22. • Functional deficits in basal ganglia of children with ADHD disorder shown with functional reasonant relaxometry. Teicher MH,Anderson CM,et al.Nat.Med. 2000 Apr; 6(4):4703

  39. CB 1 Receptors

  40. Midbrain Endocannabinoids

  41. EndocannabinoidsDecreased Sensory Input Endocannabinoids cause synaptic inhibition. This makes it more difficult for the inhibited neurons to fire.

  42. Thoughts On How Cannabinnoids May Work to Treat ADHD • Largely affect the midbrain-NA,VTA,limbic system,nucleus accumbens,substantia nigra • Causes release of dopamine • Trigger inhibitory stimulation • May slow neurotransmission speed • Allows person to focus due to fewer thoughts transmitted to cortex • Decreases emotional excitability

  43. ADD & ADHD Patients Description of Difficulty Concentrating Sufferers of ADD and ADHD describe having wave after wave of thoughts,ideas,concepts,internal and external sensory input rapidly and repeatedly wash over them. This cascade of input is overwhelming. It does not provide for the time to concentrate on any one idea,image or thought.

  44. How Cannabis Successfully Treats ADHD Cannabis slows down and decreases internal and external sensory input via synaptic inhibition.This enables ADHD sufferers to more completely and better process the information reaching the higher cortical areas of the brain. They can get their minds around the material,sit still and attend to what the teacher is saying. Patients describe being able to FOCUS.

  45. FOCUS • “Marijuana made it so I could achieve. I realized that I wasn’t stupid.” • “My son,who has ADD,initially used marijuana recreationally.He soon discovered he could sit down, do his home work much better with marijuana” • In my experience at Zona Seca, teenagers referred fro marijuana use,either have a learning disability,come from a dysfunctional family or both.

  46. Where to from here? As a clinician I’m sure that I got some of the science wrong.But that’s ok because the scientists probably have some of it wrong,too.

  47. Exciting Times for ADHD & Cannabinoids This an exciting time for cannabinoid research. • Is Piomelli right at UCI?Do we need an anandamide blocker? • Will there be more effective synthetics developed? • What percentage of ADHD patients benefit from cannabis?

  48. Conclusion • Cannabis can be efficacious in treating ADHD • There are likely several kinds and causes of ADHD and cannabis may not help all of them • Future is bright for research on the endocannabinoid system & ADHD • Future may see synthetic cannabioids or selective anandamide reuptake inhibitors

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