Ulrich Lanius, PhD - Traumatic Stress and Dissociative Symptoms (2017 Conference) (LDN, low dose naltrexone)
Dr. Ulrich Lanius is a psychologist in Vancouver, British Columbia, Canada, specializing in traumatic stress syndrome and posttraumatic stress syndrome (PTSD), with a particular interest in dissociative symptoms and the several diagnoses associated with dissociative symptoms. He discusses several of these symptoms and diagnoses.
Dr. Lanius focuses on lack of early caregiving as the vulnerability to exhibit dissociative symptoms. It has been shown to decrease the number of opioid receptors. As the stress response is associated with a large release of endogenous opioids, the result is decreased modulation, because of fewer opioid receptors. He presented a case in support of this, including MRI scans showing less cerebral blood flow in the patient with attachment problems.
Talking of defensive emotions includes talking about basic affective circuits, a term coined by Jaak Panksepp, suggesting there's a hierarchical progression of emotional responses in response to threats and stressors; both active and passive. Most mammalians look for safety in a primary attachment figure – the flight response. A young animal looks for the mother, for example. Lacking a primary attachment, the affective response is either range or anger – the fight response. If the pathways are blocked and the organism can't escape, then it goes to the path of a defensive response, which is panic, the freeze, immobilization, despair, and ultimately, death of the organism. At that point you have a strong parasympathetic activation in the nervous system, with the nervous system working towards shutting down and becoming immobile. One area that seems to mediate defensive responses is the periaqueductal grey (PAG), particularly the ventrolateral PAG, an area related to immobilization, that has a high density of opioid receptors. Along with immobilization is reduced/shallow breathing and lowered oxygen intake. In the long term, immobilization is associated with compromised immune function.
A crucial piece to understand is how people with traumatic stress syndromes will respond to opioid antagonists, including naltrexone. It is known that in addition to improving immune function, at some level naltrexone produces a withdrawal from opioids, and in the absence of a safe relationship, instead of oxytocin, there's vasopressin release. Thus, naltrexone reduces the effect of the physical restraint and the immobilization effects, and biases the nervous system towards more active defensive responses such as seeking, rage, the flight response.
Dr. Lanius presented several studies and cases showing positive results using naltrexone/opioid antagonists in patients with PTSD, depersonalization disorder, dissociative disorders, and he shared several very positive responses from clients on opioid antagonists prior to therapy. He stresses the importance of a solid therapeutic relationship with good rapport in these cases.
One of his patients was undergoing eye movement desensitization reprocessing (EMDR), a psychotherapeutic intervention, but was unable to benefit from it without high-dose naltrexone blocking the dissociative response. There were complications from the blocking: she became aware of part of herself that does not want to live. Further, she had complications with anesthesia because of naltrexone blockade. Interestingly, off naltrexone her improvements were maintained, and when dissociative symptoms interfered with EMDR, she took naltrexone only prior to the session.
Along with Bob Ferry, Dr. Lanius looked at people who had been in EMDR and other interventions for traumatic stress, and found people did not respond to the treatment. Either derealization or significant somatization blocked further proceeding. Using naltrexone or naloxone prior to EMDR result in improvement in most of them; and as time progressed, improvement continued with EMDR even without the opioid antagonists.
Dr. Lanius attributes the adverse effects of naltrexone to opioid withdrawal, and oral administration. There are a lot of opioid receptors in the gut, so when you take an opioid antagonist orally, you induce that withdrawal response. Those who have traumatic stress syndromes have an endogenous opioid activation in their system that results when you administer an opioid antagonist, resulting in gastric distress, abdominal pains, nausea, vomiting - essentially all opioid withdrawal symptoms.
Dr. Lanius presented several cases of patients with dissociative identity disorder and other diagnoses, where adjusting the dosage of low dose naltrexone (LDN) was an important therapeutic measure. Some of the cases include:
* Where naltrexone 50 mg improved the patient’s emotional regulation, as well as her chronic fatigue and arthritis pain. However at that dose, she started to bridge into old memories and became overwhelmed, so she was changed to LDN. Interestingly, LDN did not reverse analgesia like the higher doses were reported to do. She also had improved cardiac status, and decreased fatigue and pain.
* Where nighttime dosing LDN resulted in breaking through amnesia and the patient started having nightmares, breaking into dissociated memories she wasn't ready or capable to access at that point in time. The point is that when you have significant dissociative amnesia, higher doses of even LDN can be contraindicated or can have adverse effects and become quite destabilizing.
* Where LDN 4 mg prior to seeing him caused a patient to break into memories, so they reduced LDN to 0.5 mg bid which she tolerated. Gradually she was able to increase LDN in 0.1 mg steps. The point is that while a higher dose would be desirable given her medical issues (MS, complex regional pain syndrome (CRPS)), breaking through of dissociated memories make a higher dose unfeasible.
* Where a patient stable on LDN 8 mg bid was doing well until a relationship broke up and he developed psychotic symptoms. His LDN was increased to 300 mg for a week, he stabilized and went back on 8 mg bid. He did not have any major issues with not wanting to remember, so in that sense he was not dose limited, and the higher dose was definitely more stabilizing for him.
* Where a patient with depersonalization disorder, social anxiety, and attachment issues was unresponsive to psychotherapy and multiple medication trials. On LDN 50 mg there was minimal improvement, so it was increased up to 150 mg, and briefly to 200 mg – where it triggered anxiety and was less effective. Her optimal dosage was 150 mg, and in conjunction with LENS neurofeedback, ultimately normalized.
Opioid antagonists give profound ways in which patients’ lives are improved. He displays slide with the symptoms that they benefit. Interesting, some literature suggests there is a nonlinear dosage effect, where very low and high dosages are most effective, but intermediate dosages are less effective. There's some suggestion that low dose may act preferentially on presynaptic receptor sites, and high dose may activate postsynaptic receptor sites. With regard to PTSD and dissociative symptoms, the target dose is 0.6 mg/kg of body weight, usually twice daily or even three times daily; usually twice daily dosing is sufficient. At least in PTSD clients, the twice daily dosing doesn't seem to be any less effective in helping their autoimmune disorders.
If there’s concern about side effects or sensitivity, he recommends starting with LDN 0.5 or 1.0 mg and titrating upwards. Some need as low as 0.01 mg. Once on LDN for a week or more, the higher doses no longer trigger the withdrawal effect. Higher doses seem to be more effective in traumatic stress syndromes, particularly in depersonalization disorder and eating disorders. It’s a balance between results from empirical trials in contrast with working with patients. Dr. Lanius displayed a slide showing adverse effects in PTSD when using opioid antagonists, and recommends management starting at the lowest dose first. Daytime dosing is used only if there's sleep problems.
There are issues where naltrexone should be introduced carefully, because the likelihood of an adverse response is much higher, particularly without a therapeutic relationship. And, naltrexone will boost, potentially, the effects of other medications, so there needs to be some caution if they need to be within a specific range. Some of this has been documented with improving antidepressant response and anti-psychotic response in a number of studies.
Summary from the LDN 2017 Conference. Listen to the video for the show.
Further conference presentations can be found: https://ldnresearchtrust.org/ldn-conferences
Keywords: LDN, low dose naltrexone, traumatic stress syndrome, PTSD, opioid, oxytocin, dissociative, dissociation, amnesia, periaqueductal grey, PAG, eye movement desensitization reprocessing, EMDR, opioid withdrawal,