Narcotherapy in the treatment of post-traumatic stress disorders: a report of two cases.
The post-war popularity of drug-facilitated interviewing reached its peak in the late 1940s, when it was claimed that the future of narcosynthesis was infinite and the possibilities endless (Tilkin 1949). The subsequent decline of interest and utilization was rapid and almost total. A review of the North American literature from 1930 to 1978 cited 57 relevant studies, for which 1942 was the median year (Dysken et al. 1979a). In the past decade there has been a marked paucity of reports (Hurwitz 2004; Fackler, Anfinson & Rand 1997) and narcotherapy is not mentioned in current editions of comprehensive textbooks of psychiatry (Gelder, Lopez-Ibor & Andreason 2000; Hales, Yudofsky & Talbot 1999). The results of a recent British survey (Wilson 2002) imply that drug-induced abreaction may become entirely obsolete during the present century.
Post-traumatic stress disorders are said to be the most common form of anxiety neuroses in North America (Kessler et al. 1995) and it has been estimated that nearly one million individuals suffer from these conditions in the United Kingdom (Kinchin 2001). On account of the increased readiness of patients to reveal histories of sexual abuse, mental health workers have become more aware of the extent of the problem. The current wars in Iraq and Afghanistan are producing significant numbers of very severe cases. Narcotherapy achieved its greatest successes in the treatment of post-traumatic disorders, inclusive of combat neuroses, and its disuse at this time calls for some explanations.
The abreactive procedure ordinarily involves the parenteral administration of a barbiturate and a stimulant; it is troublesome and hazardous. The intravenous injection of potent substances is never free from risk and most psychiatrists lack experience with parenteral techniques, nor do they feel equipped by their training to deal competently with such emergencies as respiratory depression and laryngospasm. The recommendation that a cardiopulmonary resuscitation cart should be available at all times (Perry & Jacobs 1982) fails to provide reassurance. Some have found a safe but costly solution by calling upon the services of an anesthetist to produce the desired state of narcosis (Kolb 1985). Fortunately these hazards of the traditional procedure are inexpensively eliminated when the necessary drugs are given by mouth.
A postulated justification for the disuse of drug-facilitated abreaction is the allegation that it gives rise to false memories (Brandon et al. 1998). Apart from one passage on the treatment of hysterical amnesia in a review of physical methods of treatment in psychiatry (Sargant & Slater 1944) there is nothing in the literature that would indicate that false memories are created by abreaction or that patients are more suggestible in the abreactive state. Everyday observation of the inebriated shows that suggestibility, the readiness to acquire new ideas, is reduced by intoxication, and the psychological effects of barbiturates are similar to those of alcohol. False memories have arisen in psychotherapy and through the reading of self-help literature, but a connection with abreaction has never been established.
Finally, we must consider payment for the procedure. Is the psychiatrist who employs narcotherapy adequately remunerated for his work? For example, in Canada, where the fee schedules are set by the ten provincial governments, the unit fee for psychotherapy covers behavior therapy, aversive conditioning, psychoanalysis and therapy with intravenous drugs. The psychiatrist who undertakes narcotherapy, which traditionally involves the intravenous injection of barbiturates and stimulants, receives no greater recompense than his colleague who sits down and engages in therapeutic dialogue for the same length of time. Even the most dedicated professionals are unlikely to undertake extra work of a hazardous nature for which they are unrewarded. Canadian fee schedules are therefore a strong deterrent to the use of drug-induced abreaction; they may reflect a conviction that narcotherapy has no demonstrable value as a treatment, and should be discouraged.
That oral administration of barbiturates could replace intravenous injection was recognized during the Second World War and a combination of Luminal (phenobarbital) and Medinal (barbital) was recommended for the treatment of combat neuroses (Sargant & Slater 1940). In the abreactive treatment of psychotic patients it was claimed that intravenous injection was unnecessary unless quick action was desired (Broder 1936). Psychiatrists who employed the traditional procedure usually supplemented the barbiturate sedative with the injection of a stimulant, such as methedrine, which counteracted the soporific effects and promoted a smooth flow of speech. These intravenous stimulants are no longer commercially available, and this is another reason for adopting the oral route of administration.
It is unfortunate that, among the many published accounts of narcotherapy, there are no reports of controlled studies. Working in a general psychiatric hospital, I have never had sufficient numbers of PTSD patients to permit a formal comparison with other methods of treatment. Thus, this task must be left to others. The present report merely seeks to draw attention to a modified form of a therapeutic procedure that has shown great promise in the past and has been undeservedly neglected.
MODIFIED TREATMENT PROCEDURE
Before commencing a course of narcotherapy, it is necessary to obtain a written consent which must be based upon complete information. The patient has to be aware that he or she may be emotionally disturbed by the treatment and that it may be necessary to invoke protective measures to ensure his or her safety. For these reasons I do not give narcotherapy to outpatients. In discussing this form of treatment with the patient I describe the benefits which may be expected, but no pressure is exerted and it is made clear that the therapeutic program may be rejected without prejudice and, once started, may be stopped at any time in accordance with the patient's wishes.
Sodium amytal is given by mouth after a light breakfast and methylphenidate is ingested from 10 to 15 minutes later. If the psychiatrist is a male and the patient a female, a female nurse remains with the patient throughout the interview, and she is invited to participate verbally. At the end of the session she takes the patient back to her room and remains with her as long as is necessary. To ensure comfort and safety, sedation and other methods may be required. With male patients the presence of a male or female nurse during the interviews is optional.
The first interview is a trial for the patient, who may decide at that point to continue or to withdraw. With frail patients, unaccustomed to psychiatric drugs, I start with small quantities, such as 60 mgm sodium amytal and 20 mgm methylphenidate. For patients who are less naive and in subsequent interviews, larger quantities of these drugs are used, up to 400 mgm sodium amytal and 80 mgm methylphenidate.
The two drugs act in opposition to each other and the amounts ingested are fractions of the minimal fatal doses. While under their influence, the patients are closely observed by members of the medical and nursing staff. In healthy adults the procedure is completely safe, but special monitoring may be advisable in the treatment of vulnerable individuals, the obese, the elderly and the debilitated. In my experience the principal hazard lies in the abrupt changes that may take place in the patient's mental state, with impulses to run away or to inflict self-harm. Such outcomes are rare, but they demand precautionary safeguards.
Some workers (Dysken et al. 1979b) have suggested that the effects of sodium amytal interviews are due to non-drug factors and that the barbiturate is nothing more than a placebo. This is inconsistent with some of the dramatic outcomes that I have observed. One patient, a 45-year-old married woman, had been completely disabled for four years by an undiagnosed mental illness which had not responded to ECT or to a wide range of psychoactive drugs. She was known to have been sexually assaulted during childhood by a notorious pedophile, but she became totally mute if one attempted to question her about the incident. When she was given 120 mgm of sodium amytal she went into a state of dissociation that lasted for four days. She thought that she was nine years old and in the garden shed where the assault had taken place.
RESULTS OF TREATMENT
For several years I have offered modified narcotherapy to a series of patients who suffered from post-traumatic stress disorder. Whenever the offer of treatment was accepted, the results were satisfactory. All those treated agreed that they had been helped, and no patient has claimed to have been harmed. The total number of therapeutic sessions in the individual case varied in accordance with the severity of the illness and the speed of recovery. The minimum was two sessions and the maximum thirty-seven. From the accumulated cases I have selected two that illustrate the application of the technique and the results that may be expected. They are remarkable for the vivid nature of the case content and the duration of the follow-up.
A forty-three-year old unmarried school teacher was readmitted to the hospital in January 1992. She had been ill for twelve years with anxiety, depression and repeated suicidal gestures by overdosing and wrist slashing. Numerous admissions to regional psychiatric units and six months in a Toronto psychiatric hospital had failed to ameliorate her condition. Her case had been diagnosed as one of attention-seeking personality disorder.
In conversation with the nursing staff she confessed that her father had made sexual advances to her, an aspect of her history that she had previously denied. Because she seemed unable to elaborate she was offered narcotherapy, and after a trial with sodium amytal 60 mgm and methylphenidate 5 mgm she agreed to a course of treatment. She had twelve additional sessions in which she received from 100 to 320 mgm of sodium amytal and from 10 to 40 mgm of methylphenidate.
During these interviews the patient revealed that an incestuous relationship with her father, initiated at the age of six with the connivance of her mother, had continued into adult life, maintained by violence and threats. Four years prior to the present admission, at the age of thirty-seven, she had become pregnant by him and had undergone a therapeutic abortion.
The series of interviews was terminated by the patient, who explained candidly that she did not wish to describe the full details of her father's bizarre and sadistic sexual practices. She said: "I only tell you the things that I think will not shock you."
It is now fifteen years since the treatment was completed and during this time the patient has remained well, apart from some minor episodes of depression that have responded to medication. There have been no further episodes of self-harm and no further admissions to hospital. The author has met her from time to time in the city, and she has always appeared to be relaxed and sociable. When she has been asked if the sodium amytal interviews helped, she has replied by saying: "They took the top off it."
A forty-six-year old unemployed Native addiction counsellor was readmitted to the hospital in November 2001 at his own request. For thirty years he had suffered from horrific nightmares that had ruined both his marriage and his career prospects. He had been hospitalized on eight previous occasions with the same complaints and had derived no benefit from treatment with anxiolytics, antidepressants, neuroleptics and ECT. Overcoming a strong impulse to commit suicide, he had returned to the hospital in a final attempt to obtain relief.
Before his sixteenth birthday he had seen his older brother, who had a criminal record, blow his head off with a 303 rifle. On the day of his brother's funeral he had witnessed the death of a pregnant woman who had stepped in front of a transport vehicle while intoxicated. Three months later, responding to strange noises, he entered a house in the village and was confronted with the bodies of three children who had been assaulted and killed by a sexual predator.
In his dreams a faceless figure in black controlled a slide projector and forced him to watch depictions of these events in slow motion. The slide show was always followed by an attack of night terror in which he wrestled with the faceless figure and sought to wake up. At such points in his dreams he uttered frightening noises and on several occasions he had injured himself in his struggles. For sleeping purposes in his home he had placed a mattress on the floor of a room from which all glass articles and other dangerous objects had been removed.
Attempts had been made to treat the condition with psychotherapy, but the patient always related his experiences without any show of emotion and seemed to distance himself from them. To release and discharge the affective components he was offered drug-induced abreactive treatment. Prior to each session he took 300 mgm sodium amytal and 80 mgm methylphenidate. He was interviewed three times each week in hospital and a session lasted from two to three hours.
In addition to the three traumatic experiences, which he described in great detail, he revealed that he had been sexually abused between the ages of eight and twelve. Furthermore, he had been closely involved in a surprising number of deaths, and for three of them he believed that he was directly or indirectly responsible.
Under the influence of the two drugs he wept copiously, shouted, uttered threats, clenched his fists and banged them on the table. After each session he recovered quickly and never required close observation.
The course of treatment was terminated after twenty-seven sessions and at that point the nightmares had ceased. Five years later I met him by chance in the city. He said that the nightmares had never returned; he had remained well and had not required any further psychiatric help. He was employed and had a new girl friend.
Freud and his associates introduced the term "abreaction" in the late nineteenth century to describe a component of psychotherapy in which the patient recalled a traumatic experience and, by talking about it, discharged the associated pathogenic emotion (Breuer & Freud 1957). Their explanation of the underlying mental mechanisms is pertinent to an understanding of narcotherapy. Traumatic experiences produce feelings of anguish and under natural conditions they give rise to reactions that may be depicted as "fight or flight," often accompanied by shouting or screaming. If these normal and natural responses are wholly or partially suppressed, the unpleasant emotion becomes attached to the memory of the incident and creates a pathogenic complex. Traumatic experiences owe their pathogenicity to the intensity of the emotions, which may be too overwhelming for discharge in the normal way, or to circumstances in which discharge through appropriate action is blocked. Adequate responses of the potent, such as the mastery of an aggressor, are fully cathartic; but assaults on the impotent, who may have to suffer in silence, are likely to give rise to post-traumatic stress disorders. Among the situations that immediately come to mind are those of children who are sexually abused and those of soldiers under bombardment, who can neither run away nor take effective measures against the enemy.
Language, as Freud pointed out, serves as a substitute for action. Abreactive therapy gives the patient a unique opportunity for unobstructed talk. By using a sedative drug the cortical restraint on the expression of emotion is diminished and the anxiety that is aroused by recall of the trauma is reduced. Free use of language permits the discharge of the pathogenic affect. This technique is of maximum value in cases where shame and the fear of a mental breakdown have motivated the patient to conceal or minimize their traumatic history. Unlike those forms of treatment that use medication only to suppress the symptoms, narcotherapy may claim to have curative potential in cases of post-traumatic stress disorder. There is no rational justification for its current neglect and disuse.
Barker, P. 1992. Regeneration. London: Penguin Books.
Bleckwenn, W.J. 1930. Narcosis as therapy in neuropsychiatric conditions. Journal of the American Medical Association 95: 1168-71.
Brandon, S.; Boakes, J.; Glaser, D. & Green, R. 1998. Recovered memories of childhood sexual abuse. British Journal of Psychiatry 172: 296-307.
Breuer, J. & Freud, S. 1957. Studies on Hysteria. New York: Basic Books.
Broder, S.B. 1936. Sleep induced by sodium amytal, an abridged method for use in mental illness. American Journal of Psychiatry 93: 57-74.
Dysken, M.W.; Chang, S.S.; Casper, R.C. & Davis, J.M. 1979a. Barbiturate-facilitated interviewing. Biological Psychiatry 14: 421-32.
Dysken, M.W.; Kooser, J.A.; Haraszti, J.S. & Davis, J.M. 1979b. Clinical usefulness of sodium amobarbital interviewing. Archives of General Psychiatry 36: 789-94.
Fackler, S.M.; Anfinson, T.J. & Rand, J.A. 1997. Serial sodium amytal interviews in the clinical setting. Psychosomatics 38: 558-64.
Gelder, M.G.; Lopez-Ibor, J.J. & Andreason, N.C. (Eds.) 2000. New Oxford Textbook of Psychiatry. New York: Oxford University Press.
Grinker, R.R. & Spiegel, J.P. 1944. Brief psychotherapy in war neuroses. Psychosomatic Medicine 6: 123-31.
Hales, R.E.; Yudofsky, S.C. & Talbot, J.A. (Eds.) 1999. The American Psychiatric Press Textbook of Psychiatry, Third Edition. Washington, DC: American Psychiatric Press.
Horsley, J.S. 1936. Narco-analysis. Lancet 2: 55-56.
Hurwitz, T.A. 2004. Somatization and conversion disorder. Canadian Journal of Psychiatry 49 (3) : 172-78.
Kessler, R.C.; Sonnega, A.; Bromet, E.; Hughes, M. & Nelson, C.B. 1995. Post-traumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry 52: 1048-60.
Kinchin, D. 2001. Post-Traumatic Stress Disorder: The Invisible Injury. London: Success Unlimited.
Kolb, L.C. 1985. The place of narcosynthesis in the treatment of chronic and delayed stress reactions of war. In: S.M. Sonnenberg; A.S. Blank & J.A. Talbot (Eds.) The Trauma of War: Stress and Recovery in Viet Nam Veterans. Washington D.C.: American Psychiatric Press.
Perry, J.C. & Jacobs, D. 1982. Overview: Clinical applications of the amytal interview in psychiatric emergency settings. American Journal of Psychiatry139: 552-59.
Sargant, W. & Slater, E. 1944. Physical Methods of Treatment in Psychiatry. Edinburgh: Livingstone.
Sargant, W. & Slater, E. 1941. Amnesic syndromes in war. Proceedings of the Royal Society of Medicine 34: 757-64.
Sargant, W. & Slater, E. 1940. Acute war neuroses. Lancet 2: 1-2.
Tilkin, L. 1949. The present status of narcosynthesis using sodium pentothal and sodium amytal. Diseases of the Nervous System 10: 215-18.
Wilson, S. 2002. Survey of the use of abreaction by consultant psychiatrists. Psychiatric Bulletin 26: 58-60.
Raymond Denson, MSc (Saskatchewan), MDCM (McGill), FRCPC MRCPsych *
* Psychiatrist, Lakehead Psychiatric Hospital, Thunder Bay, Ontario; Member, Consent and Capacity Board of Ontario.
Please address correspondence and reprint requests to Raymond Denson, Apartment 704, 590 Beverly Street, Thunder Bay, Ontario, Canada P7B 6H1.
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Short Communication|
|Publication:||Journal of Psychoactive Drugs|
|Article Type:||Case study|
|Date:||Jun 1, 2009|
|Previous Article:||Visual representation tools for improving addiction treatment outcomes.|
|Next Article:||Nitrite inhalant abuse in antisocial youth: prevalence, patterns, and predictors.|