Editor's Note: Written by Dr. Frank for The Apothecarium.
Perhaps one of the more common medical recommendations for cannabis is for anxiety. This is perhaps because many conditions are associated or exacerbated by anxiety. After all, it’s not unusual for someone who’s in pain all the time to feel anxious. As for post-traumatic stress disorder (PTSD), it was once put under the umbrella of anxiety disorders, but is now considered a “trauma- and stressor-related disorder,” according to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders).
What is Anxiety and PTSD?
According to the Anxiety and Depression Association of America (ADAA), anxiety-related disorders affect 40 million adults (approx 18.1% of US adults) in the US yearly and approximately 7.7 million American adults suffer from PTSD. Anxiety disorders are often diagnosed by a range of different symptoms, depending upon the type of anxiety disorder. The different types of anxiety disorder include (and for simplicity’s sake, we shall include PTSD in the list):
Generalized Anxiety Disorder (GAD) - Excessive worry lasting 6 months or more, usually accompanied by other symptoms such as restlessness, fatigue, irritability, problems concentrating, difficulty sleeping and muscle tension. A person with GAD may become anxious in everyday situations.
Social Anxiety Disorder (SAD) - Intense fear and avoidance of social interaction, and especially situations with a high chance of negative public scrutiny or embarrassment.
Obsessive-Compulsive Disorder (OCD) - Extreme obsessions and/or compulsions, with persistent distressing thoughts and ritualized behaviors. OCD has also been removed from the umbrella of anxiety-related disorder.
Post-Traumatic Stress Disorder (PTSD) - A disorder that arises after being exposed to traumatic experiences, such as war, assault, abuse, serious accidents such as car crashes, natural disasters or any particularly extreme stressor. Flashbacks, nightmares and intrusive thoughts/memories are common symptoms for those with PTSD.
Panic Disorders - Brief attacks or episodes of intense fear, accompanying one or more symptoms such as trembling, shaking, confusion, nausea, heart palpitations, dizziness and difficulty breathing. An attack can last several minutes to several hours.
Phobias - An irrational fear of a specific stimulus or situation. Common phobias include flying, blood, water, highway driving and enclosed spaces (agoraphobia).
Selective Mutism - When a person who is normally capable of speech is unable to speak in certain specific situations or people.
Situational Anxiety - Anxiety that arises from being exposed to new places or situations.
Separation Anxiety (SepAD) - An intense fear of being separated from a specific person or place.
Most anxiety-related conditions are diagnosed after symptoms have lasted 6 months or longer. Different types of anxiety disorder can be caused by a range of factors, including being exposed to a traumatic event, persistent life stresses, an underlying endocrine disease such as hypothyroidism, genetics and, according to some theories, an “evolutionary mismatch” between people and the modern environment. Drug abuse may also cause anxiety, and some people are highly sensitive to caffeine and may have caffeine-induced anxiety attacks. Anxiety is often comorbid with other conditions, especially depression. Those with a smaller hippocampus (the part of the brain involved in memory) are at greater risk of developing PTSD.
How does anxiety and PTSD affect our brain?
Both anxiety and PTSD affect serotonin (“well-being and happiness”), norepinephrine (“flight-or-fight”) and dopamine (“reward”) receptors, as well as causing severe imbalances in the levels and production of the neurotransmitter that modulates central nervous system (CNS) activity, GABA. Low levels of GABA are found in anxiety sufferers, whereas PTSD sufferers may have overproduction of GABA in some areas of the brain and deficiencies in another. Both PTSD and anxiety sufferers tend to produce erratic amounts of serotonin, dopamine and norepinephrine, although again PTSD sufferers may have drastic fluctuations in dopamine and norepinephrine levels. Those who suffer from social anxiety may have an overabundance of serotonin, whereas those with GAD may have low levels of serotonin.
Due to the receptors PTSD and anxiety affects, the most common first-port-of-call are antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs). Other treatment modalities include therapy (e.g. cognitive behavioral therapy, or CBT), lifestyle changes (healthier eating, regular sleeping patterns, exercise), natural anxiolytics (e.g. chamomile tea) and creative pursuits (art, music, cooking, gardening). However, in some circumstances, benzodiazepines such as diazepam (Valium) and clonazepam may be prescribed.
Now, there are a lot of pluses going for antidepressants when treating PTSD and anxiety. The potential for abuse is low, and they are specific and targeted enough to help treat a lot of different conditions (e.g. chronic pain). However, antidepressants can take a long time to start working, and a person may need to try several before they find one that works. As for benzodiazepines, their potential for abuse, addiction and risk of overdose makes them a non-starter in anything but the most extreme cases. As for PTSD, there is no indication that benzodiazepines work, and may in fact worsen the condition.
There is obviously lots of merit in following a healthy lifestyle, full of regular exercise, eating healthily and sleeping properly. This is the case whether a person suffers from anxiety or PTSD or not. Yet, for many people, doing all this is just not enough. They can do all the exercise they want and eat as well as possible, and they still cannot get better. They can pop all the different SSRIs, SNRIs, tricyclics and so on, and they just can’t seem to find the right one. Another issue is that there might be “rebound” effects from suddenly stopping antidepressant use. As for benzodiazepines, down that path lies potential addiction and the worsening of problems.
Cannabis for Anxiety and PTSD
This is where cannabis comes into play. For people who don’t respond well to other drugs, cannabinoids and terpenoids may well be just the thing they’re looking for. Both cannabidiol (CBD) and tetrahydrocannabinol (THC) can attenuate norepinephrine, dopamine and serotonin receptors. As for the terpenes inside cannabis, limonene and phytol may modulate GABA levels, and linalool, pinene and beta-caryophyllene (as well as limonene and phytol) may have anxiolytic effects.
Now, this is not to say that cannabis will work for everyone who has anxiety and/or PTSD. However, there are some distinct advantages to utilizing medical marijuana for the treatment of anxiety and PTSD. Just as with antidepressants, there are some cannabinoid-terpenoid profiles that might work, and some that don’t. Dosages may also need to be determined, but unlike with antidepressants, cannabis may provide more immediate relief for those with anxiety or PTSD.
In many instances, those who use cannabis for anxiety and PTSD (and depression) may use it in conjunction with antidepressants, either to lower their intake of antidepressants or to prevent needing more addictive and/or toxic drugs such as benzodiazepines and antipsychotics. Cannabis may also act as a substitute for alcohol in social situations, which can sometimes be an issue for those with PTSD and anxiety and make problems worse.
Treating anxiety and PTSD can be tricky. First of all, determining the type of anxiety is important in order to treat it properly. Then, it’s a matter of finding the right medication, which can be difficult, especially for anxiety-related conditions where there are a wide range of symptoms. Indeed, treating an mental health condition using medication is a difficult task, as it isn’t a physical ailment that can visibly get better.
When it comes to regulating mood and overcoming a mental health issue, it is best to avoid drugs that are addictive and/or neurotoxic wherever possible (as with any health condition, really), especially as the side-effects of such medications can be similar or worse than than the conditions they’re trying to treat. Targeting the endocannabinoid system may well be one of the ideal ways of treating mental health conditions more safely.