Brain Trust: Bessel van der Kolk, MD, on Complex PTSD, Attachment, and the Limits of Pharmacotherapy

BRAIN TRUST: CONVERSATIONS IN PSYCHOPHARMACOLOGY
Series Editor Joseph F. Goldberg, MD

Joseph F. Goldberg, MD, in this installment of “Brain Trust: Conversations in Psychopharmacology,” sits down with Bessel van der Kolk, MD, to discuss the limits of pharmacotherapy for complex trauma and the emerging role of psychedelic-assisted treatment.

An event can become traumatic, according to van der Kolk, when it “leaves you speechless and actionless and also oftentimes where you don’t have anybody who can really establish a sense of safety and control.” Much of what is labeled trauma reflects a disorder of attachment, he said, and earlier exposure exerts greater effects on brain maturation. Assessment began with current functioning rather than trauma history, because trauma leaves perceptions stuck in the past. “Trauma changes your brain and changes your perspectives on whatever is going on with you right now,” van der Kolk added, and the dysfunction extends across cognitive, emotional, sensorimotor, and immune systems.

Van der Kolk regarded DSM comorbidity framing as artificial. His group’s study of 20,000 children supported a developmental trauma disorder diagnosis that DSM-5 did not adopt; these children met criteria for multiple diagnoses, including attention-deficit/hyperactivity disorder and bipolar disorder. No randomized pharmacologic trials existed for complex posttraumatic stress disorder (PTSD), and only 2 medications held FDA approval for PTSD. Antidepressants worked in depression without childhood trauma but poorly in patients with extensive trauma histories, and atypical antipsychotics were considered detrimental because dopamine blockade can erode motivation. In his trial, eye movement desensitization and reprocessing (EMDR) produced remission in most adults with adult-onset trauma, but early-life abuse and neglect required more than EMDR alone.¹

Neurofeedback, yoga, meditation, body work, and martial arts were underused adjuncts, van der Kolk highlighted. In the phase 3 MDMA trial, 88% of participants had histories of chronic abuse and neglect, yet MDMA plus therapy improved self-compassion, emotion regulation, substance use, and interpersonal functioning.² Psychedelic experiences appeared to restore time perspective—recognition that the trauma happened then, not now—and a therapeutic setting was considered essential. Psychosis was a contraindication, and patients with borderline personality disorder were excluded from the trial. SSRIs modestly reduced the effect of these psychedelic experiences, but van der Kolk noted he would not be quick to discontinue them in practice.

Dr Goldberg is a clinical professor of psychiatry at The Icahn School of Medicine at Mount Sinai in New York, NY and the immediate-past president of the American Society of Clinical Psychopharmacology.

Dr van der Kolk is a psychiatrist, researcher, and author of the New York Times best-selling book The Body Keeps the Score.

References

1. van der Kolk BA, Spinazzola J, Blaustein ME, et al. A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: treatment effects and long-term maintenance. J Clin Psychiatry. 2007;68(1):37-46.

2. Mitchell JM, Bogenschutz M, Lilienstein A, et al. MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study. Nat Med. 2021;27(6):1025-1033.