cbd oil dosage for ptsd

Cannabidiol in the Treatment of Post-Traumatic Stress Disorder: A Case Series

1 Rocky Vista University, Osteopathic Medical Student IV, Parker, CO.

Scott Shannon

2 Department of Psychiatry, University of Colorado Denver, Denver, CO.

Shannon Hughes

3 School of Social Work, Colorado State University College of Health and Human Sciences, Fort Collins, CO.

Nicole Lewis

4 Department of Naturopathic Medicine, Wholeness Center, Fort Collins, CO.

Abstract

Objectives: Cannabidiol (CBD) is a non-psychotomimetic cannabinoid compound that is found in plants of the genus Cannabis. Preclinical research has suggested that CBD may have a beneficial effect in rodent models of post-traumatic stress disorder (PTSD). This effect is believed to be due to the action of CBD on the endocannabinoid system. CBD has seen a recent surge in research regarding its potential value in a number of neuro-psychiatric conditions. This is the first study to date examining the clinical benefit of CBD for patients with PTSD.

Methods: This retrospective case series examines the effect of oral CBD administration on symptoms of PTSD in a series of 11 adult patients at an outpatient psychiatry clinic. CBD was given on an open-label, flexible dosing regimen to patients diagnosed with PTSD by a mental health professional. Patients also received routine psychiatric care, including concurrent treatment with psychiatric medications and psychotherapy. The length of the study was 8 weeks. PTSD symptom severity was assessed every 4 weeks by patient-completed PTSD Checklist for the DSM-5 (PCL-5) questionnaires.

Results: From the total sample of 11 patients, 91% (n = 10) experienced a decrease in PTSD symptom severity, as evidenced by a lower PCL-5 score at 8 weeks than at their initial baseline. The mean total PCL-5 score decreased 28%, from a mean baseline score of 51.82 down to 37.14, after eight consecutive weeks of treatment with CBD. CBD was generally well tolerated, and no patients discontinued treatment due to side effects.

Conclusions: Administration of oral CBD in addition to routine psychiatric care was associated with PTSD symptom reduction in adults with PTSD. CBD also appeared to offer relief in a subset of patients who reported frequent nightmares as a symptom of their PTSD. Additional clinical investigation, including double-blind, placebo-controlled trials, would be necessary to further substantiate the response to CBD that was observed in this study.

Introduction

P ost-traumatic stress disorder (PTSD) is a relatively common psychiatric condition with a lifetime prevalence of 6.1% in the United States. 1 PTSD often presents in clusters of symptoms, including the re-experiencing of traumatic events through intrusive memories and nightmares, avoidance of certain distressing factors, and alterations in mood, level of arousal, and cognition. Psychotherapy is the established first-line treatment for PTSD, and various psychiatric medications are also typically employed. The development of additional treatment agents is important because current medications, including selective serotonin reuptake inhibitors, serotonin/norepinephrine reuptake inhibitors, antiadrenergic agents, and second-generation antipsychotics, have questionable efficacy and often carry significant undesirable side-effect profiles.

Although the pathophysiology of PTSD has not yet been definitively described, a number of factors are suspected to contribute to the development of this disorder. One hypothesis relates PTSD to dysregulated memory retrieval through the process of reconsolidation and impaired extinction of aversive memories. 2 The endogenous cannabinoid system has been shown to play an important role in the process of aversive memory extinction through the activity of central CB1 receptors. 3 Two cannabinoid receptors are known to exist in the human body: CB1 and CB2 receptors. CB1 receptors are located mainly in the brain and modulate neurotransmitter release in a manner that prevents excessive neuronal activity, thus calming and decreasing anxiety. CB1 receptors also have a role in reducing pain, inflammation, regulating movement and posture control, and regulating sensory perception, memory, and cognitive function.

Cannabidiol (CBD) is known to have multiple physiologic mechanisms of action, including 5-HT1A serotonergic agonism, adenosine and opioid receptor modulation, activation of the endogenous endocannabinoid system, antagonism at GPR55 receptors, and activation of transient receptor potential channels. 4,5 CBD’s activity at 5-HT1A receptors may drive its neuroprotective, antidepressive, and anxiolytic benefits, although the mechanism of action by which CBD decreases anxiety is still unclear. 6 CBD was shown to be helpful for decreasing anxiety through a simulated public speaking test at doses of 300–600 mg in single-dose studies. 7–9 Other studies suggest that lower doses of 10 mg/kg have a more anxiolytic effect than higher doses of 100 mg/kg in rats. 10

Of particular interest to this study is the effect of CBD on the endogenous cannabinoid system. CBD has minimal affinity for CB1 and CB2 receptors, 11 but it does indirectly cause activation of CB1 receptors by increasing the availability of endogenous endocannabinoids. Anandamide is an endogenous cannabinoid that acts as a partial agonist at CB1 receptors. It is metabolically deactivated by the enzyme fatty acid amide hydrolase (FAAH). CBD has been shown in some studies to inhibit FAAH, thus increasing the availability of anandamide and causing activation of the endocannabinoid system. 12 Studies in rodent models have shown that pharmacologic activation of the endocannabinoid system through CB1-receptor agonist agents leads to decreased behavioral response to aversive memories in rodent models through the inhibition of memory reconsolidation and enhanced extinction. 13–15 This early research suggests that agents such as CBD that cause indirect activation of the endocannabinoid system may have utility in the treatment of PTSD.

Current evidence regarding the use of CBD for PTSD in humans is minimal. One case report showed that administration of 12–37 mg of oral CBD daily was associated with a reduction in anxiety symptoms and sleep disturbances in a 10-year-old patient with PTSD due to sexual trauma. 16 Another study showed that 32 mg of inhaled CBD resulted in consolidation of aversive memory extinction and attenuation of explicit fearful responding in healthy human subjects. 17 See Bittencourt and Takahashi 18 for a recent comprehensive review of pre-clinical and clinical studies regarding the relationship of CBD to PTSD. To date, no clinical trial evaluating the effectiveness of CBD in reducing symptoms of PTSD in humans has been completed.

The hypothesis of this study was that patients with DSM-5-diagnosed PTSD who were administered CBD along with routine psychiatric care would show a decrease in PTSD-specific symptomatology. This hypothesis was based on prior rodent and limited human studies that suggest that (1) CBD may cause decreased response to and increased extinction of aversive memories, and that (2) CBD may have an anxiolytic effect, which, in turn, would have therapeutic value in patients with PTSD. To this end, we conducted a retrospective file review of adult patients with PTSD who were treated with CBD as part of standard psychiatric care in an outpatient clinic. The goal of this review was to examine the tolerability of CBD and its effectiveness in PTSD symptom reduction.

Materials and Methods

Design and procedures

This article describes a retrospective chart review of adult psychiatric patients with a diagnosis of PTSD who consented to treatment with CBD as augmentation to routine psychiatric treatment at an outpatient psychiatric clinic. All current patients with a diagnosis of PTSD were considered for treatment with CBD between February 2016 and May 2018. Patients were not excluded based on the presence of other psychiatric comorbidities (aside from an active thought disorder) or concurrent use of cannabis. The diagnosis of PTSD was established through clinical evaluation by a mental health professional (psychiatrist, psychiatric nurse practitioner, or physician assistant). Inclusion criteria for the present analysis required a cut-off score of 33 on the Post-Traumatic Stress Disorder Checklist for the DSM-5 (PCL-5) 19 and a minimum of two consecutive follow-up appointments after the initial intake appointment. The final sample consisted of 11 adult patients with a diagnosis of PTSD and who met inclusion criteria.

After the initial baseline assessment, PCL-5 assessments were completed by patients every 4 weeks to monitor changes in the severity of PTSD symptoms. In addition to CBD, patients also received routine treatment in the form of psychiatric medications, various psychotherapy modalities, and standard integrative treatments, as indicated for their diagnoses of PTSD and other psychiatric comorbidities. These integrative treatments often included dietary changes, herbal supplementation, neurofeedback, and intravenous infusions of vitamins and minerals.

Four patients received CBD as an oral capsule only. One patient only received CBD in the form of an oral liquid spray. Fifty-five percent (n = 6) of patients received both forms of CBD either concurrently or sequentially over the course of the study. The form of CBD (capsule vs. liquid spray) was determined by provider and patient preference. The CBD products used in this study were supplied by CV Sciences. Capsules were demonstrated by high-performance liquid chromatography with ultraviolet detection (HPLC-UV) to contain 22–28 mg of CBD per capsule. Patients were instructed to take whole capsules, which were assumed to contain 25 mg of CBD for dosing purposes. Patients were instructed to take liquid CBD as a specified number of sprays from a spray bottle. The liquid product used in this article was demonstrated by HPLC-UV to contain between 425 and 575 mg of CBD in total per bottle, equating to about 1.5 mg of CBD per spray.

Patients were instructed to take CBD once or twice per day based on severity of symptoms. The median starting oral capsular dose was 25 mg per day (range: 25–100). The median dose of liquid CBD given throughout the study was 9 mg per day (range: 1–16). The mean total starting dose of CBD (liquid or capsular or both) was 33.18 mg (standard deviation [SD] = 23.34). The mean total dose of CBD prescribed at the 8-week follow-up appointment at the conclusion of the study period was 48.64 mg (range: 2–100). The dose of CBD was adjusted at each 4-week appointment based on the patient’s presentation and experience. Most patients received an increase in the dose of CBD because treatment was provided to maximize PTSD symptom reduction, which seemed to be directly correlated with dose. These doses are much lower than the doses used in the previous clinical literature for multiple reasons. The first is that lower doses appear to elicit an adequate clinical response in our experience. Second, the current retail cost of CBD would make the use of 600 mg per day cost-prohibitive. Finally, doses for the liquid spray route of administration are typically lower than that of capsules and are usually measured as single milligrams of CBD per spray, thus rendering higher doses impractical for patients relying on liquid CBD.

Informed consent was obtained for each patient at their intake appointment. Appointments every 4 weeks included clinical evaluation and documentation of patients’ PTSD symptomatology through PCL-5 questionnaires. Concurrent psychiatric medications were held constant or changed according to routine clinical practice, whereas CBD was often intentionally used as a method of decreasing or avoiding the use of psychiatric medications. CBD was added to care, dropped from care, or refused as per individual patient and practitioner preference. The Western Institutional Review Board approved a retrospective analysis of the charts of patients with a diagnosis of PTSD who received CBD as part of their treatment program.

Setting

Wholeness Center is a large mental health clinic with a focus on integrative medicine and psychiatry. Practitioners from a range of disciplines (psychiatry, naturopathy, acupuncture, neurofeedback, yoga, etc.) work together in a collaborative and cross-disciplinary environment. Based on existing research and patient experience, CBD had been widely incorporated into clinical care a few years before this study.

Sample

Characteristics of the study sample are presented in Table 1 . The average age of the population in this study was 39.91 (range: 22–69, n = 11). The majority (73%, n = 8) of patients were female. On average, patients were concurrently taking three psychiatric medications, including antidepressants, mood stabilizers, anxiolytics, and stimulants. One patient used cannabis daily throughout the study. Overall, 73% (n = 8) of patients were concurrently receiving psychotherapy as part of their overall care. Patients had on average 1.8 comorbid psychiatric conditions in addition to their PTSD diagnosis, including anxiety, mood, personality, and sleep disorders.

Table 1.

Characteristics of the Patient Population and Concurrent Treatments Received

CBD for PTSD: Benefits, Dosage, & Side-Effects

CBD may help eliminate stress & anxiety from PTSD.

Learn how it works, how much to take, and what CBD oils are most effective.

Article By

PTSD affects at least 10% of people at some stage in their life [1].

Most of us have experienced trauma in some way. It can come from many places — abuse, war, accidents, disasters, or traumatic loss. It can overwhelm and affect our ability to cope. Response to trauma can have devastating consequences.

If someone is feeling distressed, disconnected, or isolated after experiencing or witnessing a life-threatening event, they may have PTSD. Current treatment methods are often unsuccessful and some have unwanted side effects.

Recently, studies have confirmed the ability of cannabidiol (CBD), a component of Cannabis sativa to be extremely beneficial in improving PTSD symptoms.

Here, we discuss PTSD, its symptoms, and how high-quality CBD oil products can help to support trauma recovery.

Let’s get started.

MEDICALLY REVIEWED BY

Updated on November 13, 2021

Table of Contents
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Can CBD Oil Help With Post Traumatic Stress Disorder (PTSD)?

Researchers have discovered many promising benefits of CBD to alleviate the symptoms associated with the disorder — especially in people that haven’t responded well to conventional therapies.

The benefits of CBD oil for PTSD include:

  • May prevent nightmares
  • may prevent the formation of “fear memories”
  • Alleviates symptoms of anxiety & depression
  • Alleviates insomnia

1. It Stops Nightmares

Clinical Trials have shown that CBD ceased or significantly reduced flashbacks, nightmares, and persistent memories in patients with PTSD [7].

2. It Prevents The Formation of Fear Memories

CBD disrupts the feelings of long-term fear memory processing, consequently reducing stress and anxiety [8].

3. It Reduces Anxiety and Depression Symptoms

CBD has a range of calming effects that reduce anxiety, panic attacks, compulsiveness, and the long-term effects of stress [9].

4. It Helps With Insomnia

CBD improves the quantity and quality of sleep and reduces night sweats. [10]

What’s The Dose of CBD Oil For PTSD

If you’re considering trying CBD oil for the first time, it’s important to start with a small dose and increase gradually.

Dosage recommendations vary and depend on the product you choose. Use our CBD dosage calculator below to find the best dose based on your weight and desired strength.

The most common method of taking CBD oil is in the form of drops. Place the dose under your tongue where it’s easily absorbed and swallow after 30 seconds to a minute.

Studies have shown high dosage ranges from 12 mg to 25 mg of CBD can significantly decrease anxiety symptoms, taking effect within 1-2 hours after taking the oil [1].

The key is to start low and go slow.

Be patient. Keep a daily journal of dosage and track your symptoms. You’ll know you’ve reached the ideal dose when your symptoms start to improve.

CBD Oil Dosage Calculator

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Endocannabinoid Dysfunction & PTSD

The two major cannabinoids found in Cannabis, tetrahydrocannabinol (THC) and cannabidiol (CBD), are both compounds that influence the body’s endocannabinoid system (ECS) but have very different effects.

Recently, researchers have focused on the importance of the endocannabinoid system as an essential emotional regulating system the body uses to maintain homeostasis — or support ‘balance’ in the internal environment despite changes in the external environment.

The ECS plays a crucial role in brain and nervous system function and is involved in modulating other factors such as appetite, sleep, pain, and cognitive function [9].

Researchers believe that chronic stress, or a traumatic event, can impair the ECS signaling in the brain, therefore, leading to a host of symptoms described above.

For those with PTSD, the ECS system is integral to the regulation of emotional behavior, learning, and responses to traumatic events.

To break it down, CB1 and CB2 are receptors that cannabinoids like CBD target.

The CB1 Receptors: Regulating the Brain & Nervous System

These are found in the brain and the nervous system. CB1 receptors play a role in fear memory formation, appetite, pain tolerance, and mood. The mood enhancing neurotransmitter anandamide activates CB1, and when anandamide levels are low, it creates a deficiency of CB1 receptors leading to increased levels of stress and anxiety.

The CB2 Receptors: Regulating Pain & Inflammation

The CB2 receptors regulate inflammation, a primary cause of many diseases.

High concentrations of CB2 receptors are found in the immune and gastrointestinal system. CB2 receptors bind with CBD and regulate appetite, immunity, inflammation, and pain.

It’s thought that in people with PTSD, ECS signaling is disrupted due to endocannabinoid deficiencies or excess — resulting in increased anxiety, fear, and unpleasant memories.

Most cannabinoids act on both CB1 and CB2 receptors, helping them to regain normal function.

As a result, CBD may be useful for PTSD patients.

CBD vs. THC for PTSD

CBD is the primary non-psychoactive component of cannabis and has anti-inflammatory, neuroprotective, anxiolytic and antipsychotic actions— it’s different to THC— which produces the mind-altering effects you may commonly hear about, also known as causing a ‘high’.

CBD doesn’t make you ‘high’— hence its popularity as a therapeutic agent.

Another advantage over other agents (such as THC) is CBD has fewer complications at high doses [1].

Research Supports CBD for PTSD

Promising research shows that CBD is effective in attenuating some of the major symptoms of PTSD— such as preventing the consolidation of fear memories, reducing anxiety and improving sleep.

In a recent 2018 review, researchers found that CBD offers a safe, therapeutic alternative for treating PTSD— with significant improvements in these symptoms, particularly in reducing the retention of unpleasant memories [1].

Other research has confirmed that nabilone, a synthetic cannabinoid, is effective in blocking trauma-related nightmares in patients that did not respond to traditional therapies [8].

As acceptance of CBD widens, more countries have approved the use of medical-grade cannabis for the treatment of PTSD. CBD is recognized as a suitable treatment option with its ability to reduce anxiety and depression, improve sleep, and eliminate flashbacks — all without risk of serious side-effects.

What is PTSD?

PTSD is a chronic psychological condition that can develop after experiencing a traumatic event.

You may be wondering if you or someone you care about has PTSD.

Often, people don’t believe they meet the criteria or have the ‘right’ to have PTSD, because it’s regularly associated with first responders and military veterans.

However, PTSD can affect anyone.

What is a Traumatic Event?

Traumatic events can mean experiencing or witnessing life-threatening events that cause intense fear or threat to safety.

Some Examples of Traumatic Events Include:
  • Domestic violence or abuse
  • Witnessing someone being killed or seriously injured
  • Surviving a car/train/bus accident or plane crash
  • Surviving a heart attack or receiving a serious medical diagnosis
  • Being a victim of rape or sexual assault
  • Victim of a crime, kidnapping, stalking or torture
  • Experiencing a life-changing event, such as divorce, unemployment or the death of a loved one
  • Experiencing a natural disaster like bushfires, earthquakes, floods
  • Experience in war or civil conflict or terrorist attack

What Are The Symptoms of PTSD?

People living with PTSD often experience multiple symptoms as the body and mind try to cope with the stressful event.

PTSD can manifest in many ways — developing into anxiety and depression or reckless behavior. Gut issues, migraines, headaches, and reduced immunity are common symptoms associated with PTSD.

Signs & Symptoms of PTSD (According to The Anxiety and Depression Association of America):
  1. Flashbacks of the trauma
  2. Physical symptoms (such as racing heartbeat, sweating, brain fog)
  3. Trouble sleeping
  4. Overly emotional, mood alterations (such as rage, shame, blame, negativity)
  5. Emotional detachment
  6. Negative beliefs and feelings
  7. Intrusive thoughts and memories
  8. Hypervigilance/anxiety
  9. Living in fear
  10. Nightmares and strange dreams
  11. Difficulty maintaining employment
  12. Difficulty concentrating
  13. Avoidance and Social isolation
  14. Substance abuse

PTSD symptoms can last between a few months to many years after the event — sometimes leading to chronic illness.

Sufferers often feel like they’re on guard, or something’s always about to go wrong, and they’re left feeling exhausted and in fear — which can continue for many years after the event.

Bodily symptoms of shortness of breath, tremors, increased heart rate, memory loss, and poor concentration can hijack our ability to lead a healthy life.

Risk Factors for PTSD

Anxiety and fear are normal adaptive responses that help us cope with threats to our survival. Not everyone who experiences a traumatic event will develop PTSD, but some factors can influence their likelihood of developing it.

Some risk factors of PTSD include:

  • A long-lasting or intense trauma (such as childhood abuse or domestic violence)
  • First responders and military personnel where there is greater exposure to traumatic events
  • Having existing anxiety and depression
  • A family history of anxiety and depression

For survivors of trauma, it can be extremely difficult and frustrating to try to understand the psychological and physical changes occurring — and what can be done to ease them.

How Is PTSD Diagnosed?

A doctor may perform a physical exam and a psychological assessment, using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

PTSD is identified by signs and symptoms in the following three categories for a period extending from 1 month [3]:

  1. Reminders of the Exposure — Flashbacks, nightmares, intrusive thoughts
  2. Activation — Hyperarousal, agitation, insomnia, irritability, aggression, impulsiveness
  3. Deactivation — Numbing, isolation, avoidance, confusion, anxiety, depression

How Trauma Affects The Nervous System

The nervous system is a complex system that involves nerves and cells, known as neurons, which transmit signals from the brain to various parts of the body.

When the brain experiences any event that has negative consequences from a stressful or dangerous situation, the hormone adrenaline kicks in via the sympathetic nervous system. This is commonly known as ‘fight or flight’ which is a natural, built-in stress response.

However, in PTSD, the stress response is heightened, and instead of returning to normal soon after the threat is over, it’s pushed beyond its limits, and becomes ‘stuck’.

The nervous system loses its ability to self-regulate, leading to psychological and physical distress.

This state is known as hypervigilance. The body is continuously alert in order to avoid danger. As a result, people can startle easily, have increased sweating, a rapid heartbeat, and quick breathing.

Conventional Treatments for PTSD

Conventional treatment usually involves psychotherapy, and can also include medications, such as antidepressants to improve symptoms.

The Mayo Clinic explains the symptoms, causes, current diagnosis, and treatment to treat both children and adults with PTSD.

Those suffering PTSD symptoms often feel their only option is a life relegated to pharmaceutical drugs and therapy. Medications have their place and can be life-saving — but are often ineffective.

Unfortunately, remission in PTSD patients is relatively low. These medications can also have unwanted side effects [4], including:

  • Nausea
  • Dry mouth
  • Weight gain
  • Sexual dysfunction
  • Insomnia
  • Constipation/diarrhea
  • Dizziness
  • Headache
  • Worsening of depressive symptoms

Opioids are also prescribed to patients with PTSD, however, they’re highly addictive medications and patients with PTSD may be at a higher risk of developing opioid use disorder compared to patients without PTSD.

Thankfully CBD offers a safer treatment option for people with PTSD without the side effects. However, CBD interacts with many medications.

If you’re thinking about trying CBD oil, it’s important you speak with your doctor before stopping other medications.

When combined with conventional treatment, natural therapies can be beneficial in recovery from PTSD in addition to lifestyle modifications such as:

1. Yoga & Meditation

Research has shown yoga improves emotional regulation, heart rate variability and reduces anxiety and stress [5].

2. Good Sleep & Hygiene

Ensure enough quality sleep and rest by adopting healthy sleeping habits. Relaxation exercises and improving your sleeping environment so it feels restful and comfortable will help.

In addition to getting enough sleep, showering and taking good care of your hygiene goes a long way to maintain your mental health.

3. Leverage Social Connection & Close Relationships

Use support networks such as family and friends or organizations in your local area. Depending on where you live, there are likely support groups where you can connect with others who have PTSD. Meetup is another excellent way to bond with like-minded people.

4. Exercise

A natural and inexpensive way to improve mood, appetite, and sleep is by finding an enjoyable way to get movement into your day — even if it’s simply going for a walk, preferably in nature.

5. Eating a Well-balanced & Clean Diet

Limit caffeine and alcohol can decrease anxiety symptoms [6]. A poor diet high in sugar and processed type foods can lead to low mood, fatigue, increased anxiety, and weight gain.

Although PTSD is not curable, it doesn’t have to run your life.

Key Takeaways: Using CBD For PTSD

Living with PTSD can be difficult. There is no cure but there is hope.

Used in addition to therapies, CBD may relieve many of the symptoms related to PTSD — such as anxiety, depression, insomnia, and prevent nightmares and flashbacks.

CBD Oil offers a safe and effective treatment to reduce symptoms and improve quality of life.