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8 doctor focus cannabis patient care | vol. 3 no. 4 cannapatientcare.com doctor focus Cannabis for Anxiety and PTSD D U S T I N S U L A K , D O Anxiety, Trauma, and the Endocannabinoid System Anxiety disorders are the most common type of psychiatric disorders, and they're one of the most common conditions for which people use cannabis. One review found that among 6665 cannabis users with data collected from 13 different studies, 52% of the subjects reported using cannabis for anxiety, making it the second most commonly treated symptom, following pain (1). Anxiety disorders come in many forms, including generalized anxiety, social anxiety, and panic disorders. While symptoms vary depending on the specific anxiety disorder, it's been my clinical experience that any of the anxi- ety disorders can be treated with a high rate of success when cannabis is used appropriately. Perhaps this is related to the high density of cannabinoid type 1 (CB1) receptors in a brain region called the amygdala and in the sympathetic (that is, fight or flight) centers of nervous system. The amygdala plays a large role in modulating fear and anxiety, and its response to anxiety-provoking cues is exaggerated in people with anx- iety disorders; stimulating CB1 can dampen this excessive ac- tivity. Similarly, the sympathetic nervous system contains CB1 receptors that will also dampen excessive activity related to the physical effects of anxiety like racing heart rate, sweat- ing, or trembling. Though they are closely related to anxiety disorders, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) created a new categor y for "trauma- and stressor-related disorders" that includes acute stress disor- der and post-traumatic stress disorder (PTSD) (2). These con- ditions develop as an abnormal adaptation to a traumatic event and symptoms include intrusive thoughts, nightmares and flashbacks, avoidance of reminders of the trauma, neg- ative changes in cognition and mood, irritability, and in- creased sensitivity and reactivity known as hyper vigilance, a perpetual scanning of the environment to search for any- thing threatening. Like anxiety disorders, evidence suggests endocannabinoid system (ECS) dysfunction may contribute to trauma-related disorders. Reduced blood levels of the endocannabinoid anandamide (AEA), abnormal CB1 receptor signaling, and a compensatory increase of CB1 receptor availability are associated with PTSD and correlate with the degree of intrusive symptoms (3). For example, in one study of 46 individuals in close proximity to the World Trade Center at the time of the 9/11 attacks, the 24 subjects who met diagnostic criteria for PTSD had signif icantly lower circulating levels of the endocannabinoid 2-AG than those who did not have PTSD. Those with the lowest levels of AEA levels had the most intrusive symptoms, consistent with animal data indicating that reductions in AEA promote retention of aversive emotional memories (4). Although anxiety disorders are categorized separately from trauma-related disorders in the allopathic psychiatry mod- el, in my experience, most anxiety symptoms can be traced to traumatic or overwhelming experiences and the behavio- ral patterns that emerge thereafter. I suspect that regardless of the diagnosis, cannabis is likely working similarly in people with anxiety disorders or trauma-related disorders: dampen- ing the anxiety response to certain cues or triggers, reducing the intensity of fight or flight symptoms, perhaps preventing the development of PTSD after a traumatic event, and, as de- scribed below, healing the traumatic memories themselves. Why Does Cannabis Succeed Where Other Treatments Fail? PTSD is often resistant to traditional antidepressant and an- ti-anxiety medications, in part because these treatments fail to address memory-related dysfunction seen in people with PTSD, such as the inability to extinguish learned fear responses, to suppress retrieval of traumatic memories, to acquire safety signals, and to dampen the over-consolidation 1 process taking place right after reexperiencing symptoms. [*Note that consoli- dation is the process of transforming a short-term memory into a long-term memory. People who re-experience trauma can increase the consolidation of the traumatic memory with each re-experiencing episode, worsening the condition.] The ECS is an important part of our ability to extinguish the emotional charge behind, and even forget our traumatic mem- ories. Cannabinoids may be ideal for treating PTSD due to their dual anti-anxiety and memory-modulating effects. Ani- mal and early clinical research have produced encouraging re- sults targeting the extinction of fear memories, which could "reduce the conditioned fear and anxiety responses triggered by trauma reminders, increasing patients' general ability to actively cope with the trauma without affecting the original memory trace" (5).