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Ann M. Inouye Alpert Medical School of Brown University, Providence, RI, USA

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Aaron S. Wolfgang Walter Reed National Military Medical Center, Bethesda, MD, USA
Uniformed Services University, Bethesda, MD, USA
Yale School of Medicine, New Haven, CT, USA

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Lianne T. Philhower Chaminade University of Honolulu Hawaii School of Professional Psychology, Honolulu, HI, USA

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Abstract

In 2021, the final series of phase 3 clinical trials looking at MDMA-AT for treatment-resistant post-traumatic stress disorder (PTSD) found that 71.2% of 3,4-methylenedioxymethamphetamine (MDMA) full-dose participants no longer met criteria for PTSD. MDMA-assisted therapy is not US Food and Drug Administration (FDA) approved in treating borderline personality disorder (BPD), and while PTSD is quite different from BPD, it is possible that some of the beneficial effects of MDMA-assisted therapy may be applicable in treating BPD. Interviewing two clinicians utilizing dialectical behavioral therapy treatment and two MDMA-assisted therapy clinicians was one way to examine the phenomenology of MDMA-assisted therapy with BPD individuals in a thoughtful manner. An exploratory, qualitative, interview-based study assessed clinicians' perspectives of MDMA-assisted therapy and BPD and increased our understanding of underlying therapeutic mechanisms and processes and the role of pharmacological factors in these treatment modalities, optimizing treatment context, and leading to improved clinical responses and patient recovery. The codes generated unique perspectives of the participants revealing a chronological narrative which included three phases of treatment.

Abstract

In 2021, the final series of phase 3 clinical trials looking at MDMA-AT for treatment-resistant post-traumatic stress disorder (PTSD) found that 71.2% of 3,4-methylenedioxymethamphetamine (MDMA) full-dose participants no longer met criteria for PTSD. MDMA-assisted therapy is not US Food and Drug Administration (FDA) approved in treating borderline personality disorder (BPD), and while PTSD is quite different from BPD, it is possible that some of the beneficial effects of MDMA-assisted therapy may be applicable in treating BPD. Interviewing two clinicians utilizing dialectical behavioral therapy treatment and two MDMA-assisted therapy clinicians was one way to examine the phenomenology of MDMA-assisted therapy with BPD individuals in a thoughtful manner. An exploratory, qualitative, interview-based study assessed clinicians' perspectives of MDMA-assisted therapy and BPD and increased our understanding of underlying therapeutic mechanisms and processes and the role of pharmacological factors in these treatment modalities, optimizing treatment context, and leading to improved clinical responses and patient recovery. The codes generated unique perspectives of the participants revealing a chronological narrative which included three phases of treatment.

Introduction

Despite extensive research showing evidence that treatment for Borderline Personality Disorder (BPD) is effective, almost half of BPD individuals will never fully recover over their lifetime (Videler, Hutsebaut, Schulkens, Sobczak, & van Alphen, 2019). A treatment time of one to three years shows an initial 85% remission rate (Biskin, 2015) of resolving BPD's acute symptoms of suicidality, self-harm, and impulsivity. However, the underlying, “temperamental” symptoms of sadness, unstable interpersonal relationships, lack of self-identity, emptiness, and fear of abandonment often remain despite treatment, which causes 10% of BPD individuals to relapse into suicidal behavior over their lifetime (Videler et al., 2019) (Table 1).

Table 1.

Summary of results

Code SystemFrequency
Phase 1-Emotional and Behavioral Safety (Dialectical Behavioral Therapy)0
DBT Stage-Trauma Processing3
Emotional and Behavioral Safety\DBT Stage 1-Behavioral Stabilization9
Client Fitness for Treatment12
Motivation/Perseverance14
Therapist0
Acceptance and Change1
Clinician Fitness for BPD and Treatment19
Compassion and Empathy8
Support7
Duties36
Boundaries and Tolerance (+)15
Suicidality16
Consultation7
Patients Accepting Treatment as Painful but Worthwhile2
EVPs for Trauma Processing2
Trauma15
Handling Dissociation2
Regression4
DBT Treatment Goals0
Hierarchy5
DBT Treatment for Self-Identity3
Etiology3
Fragmented Sense of Self7
Skill Building14
Group3
Radical Acceptance3
Acceptance and Change9
Change6
Acceptance5
Grounded in Reality6
Emptiness5
Guilt and Shame7
Lack of assertiveness5
Mastering Over Regulating Thoughts, Feelings, and Behaviors12
Distortions6
Emotionally Sensitive and Emotionally Regulated w/Self-Validation4
Emotional Dysregulation6
Understanding Emotions4
Emotional Self-Validation7
Wise Mind2
Support Network5
Stigma-Lack of Access10
De-Stigmatization2
Lack of Access5
Phase 2-MDMA-AT0
MDMA Therapy Orientation6
Therapist Role2
Suicidality5
Reverence for the Medicine10
Understanding Dosing and How to Handle Adverse Events4
Concomitant Medications4
Booster5
No Booster3
Skillset7
Support5
Preparation7
Guidance4
Mapping the Treatment4
Unpredictable4
Embodiment and Mentalization2
Back to the Self (Inner Healing Intelligence)5
Trauma95
Attachment Trauma (BPD), Shattered Cohesive Self21
Mind-Body3
Unconscious Intent7
Somatic4
Coherent Self/Relationship with Self12
Relationship with Others8
Defenses/Coping9
Support & Recovery21
Therapy8
Integration21
Setting/Support9
Integration11
Preparation56
Client Readiness5
Level of Functioning11
Regression8
Experimental Session's Process19
Physical Reactions5
Phase 3-Life Worth Living0
Life Worth Living17
Mind Body Connection19
Support31
Acceptance of Past without Hyperarousal/Finding Peace17
Coherent Self12

Individuals with BPD are thought to be at the “border” of psychosis and neurosis, always suffering from difficulties with emotion regulation. They struggle with self-identity and self-worth and are constantly processing their external environments to provide themselves with meaning (Goodman & Yehuda, 2002). They fight an endless battle against being unable to embody fundamental virtues of self-identity, trust, belonging, love, and worthiness. They are constantly searching for a sense of safety (Gabbard, 2014). All of these struggles are rooted in the underlying pain and viscous shaming cycle they endure. With therapy, they no longer have to stand on a border between safety and fear and can learn to build their self-worth and no longer be controlled by the disorder (Linehan, 2016).

BPD is a long-term pattern characterized by an unstable sense of self, self-image, and emotions. Research has shown that BPD symptoms occur in interpersonal relationships that are marked by irregular social cognition. When considering BPD individuals' accuracy in inferring others' mental states, it has been shown that they are likely to have biases in mental state attribution (Roepke, Vater, Preißler, Heekeren, & Dziobek, 2013). Research also has suggested that individuals with BPD have impairments in the attribution of emotions, thoughts, and intentions of others, which is linked to childhood trauma and comorbid PTSD (Roepke et al., 2013). Neurobiologically, BPD appears to affect the frontal-limbic network of neurons. Although the etiology is unclear, it is apparent there is a complex interplay of genetics, neurobiology, child development, and social factors (Brodsky & Stanley, 2002).

Research provides a BPD heritability estimate of around 40% (Bornovalova, Hicks, Iacono, & McGue, 2009). A family study investigating clinically diagnosed BPD in both individuals and their relatives found an absolute heritability risk of 14.1% in first-degree relatives, which corresponds to a 3.9 times increased heritability probability (Gunderson et al., 2011).

The prevalence of BPD is believed to occur in 1–2% of the general population. Heritability traits for BPD include (Bornovalova et al., 2009):

  1. Epigenetics (the stress effect on acetylation and the expression of DNA)

  2. Genetics (DNA)

  3. Development (attachment and parenting styles in the development of neurocircuitry)

  4. Learned behavior (the child's adaptation to the behaviors of their primary caregivers)

When a child develops an attachment style towards their parent that is unstable and essentially untrustworthy, their source of psychological and emotional support will also evolve to become unstable and untrustworthy of self and others. This is classically referred as an anxious-ambivalent attachment style. A majority of BPD patients have endured a history of abuse, neglect, and/or traumatic experiences, causing them to be anxious about normal daily activities (Gunderson et al., 2000).

According to attachment style theory, there is a strong association between BPD and all insecure attachment styles (Agrawal et al., 2004). An insecure attachment style can influence an individual's approach to relationships. It is characterized by fear or uncertainty, and includes ambivalent, avoidant, and disorganized subtypes. In each of these attachment subtypes, BPD individuals demonstrate a longing for intimacy but are concerned about dependency and rejection. Furthermore, the avoidant attachment style seen in BPD adults was positively related to impulsivity and negative affectivity—which leads to the experience of a poor self-concept and negative emotions, including fear, anger, disgust, etc. (Scott et al., 2009). The high prevalence and severity of insecure attachments support the diagnostic factor regarding problematic interpersonal relationships (Agrawal et al., 2004).

Theoretical framework

BPD is primarily treated with psychotherapy, in which a patient interacts individually with a therapist, often in conjunction with a group setting. Most treatments for BPD last one to three years (Biskin, 2015), although research suggests that most BPD individuals need extended, sometimes lifelong psychotherapy to resolve interpersonal problems and attain and sustain lasting improvements in their quality of life and overall functioning (Videler et al., 2019). Medications that are available for BPD patients can alleviate certain symptoms associated with BPD temporarily. However, they show insignificant effects and do not target specific BPD neurological pathways since these pathways are not well researched. Psychotherapies are recommended as first-line treatment (Brodsky & Stanley, 2002).

To date, five evidence-based psychotherapeutic approaches are used: cognitive behavioral therapy (CBT), mentalization-based therapy, schema-focused therapy, transference-focused psychotherapy (TFP), and dialectical behavior therapy (DBT; Choi-Kain, Finch, Masland, Jenkins, & Unruh, 2017). Treatment modalities include weekly individual sessions with a psychotherapist, one or more weekly group sessions with a psychotherapist, and meetings for therapists to consult with other clinicians or supervisors. Although it is not established that one approach is better than the other, DBT is the most extensively studied of the five approaches. Both DBT and TFP have been shown to have efficacy in randomized controlled trials (American Psychiatric Association Practice Guidelines, 2001).

Psychotherapeutic interventions for BPD have limitations, including limited treatment efficacy. For instance, a meta-analysis study comprised of 2,246 participants found only small to moderate effect sizes for DBT (Hedges' g = 0.34) and TFP (Hedges' g = 0.41) on BPD outcomes (BPD symptoms, self-harm, and suicidal behaviors) when compared to treatment as usual (Cristea et al., 2017). Similarly, a longitudinal study involving 41 BPD outpatient patients revealed that ten years post-treatment, 45% of the individuals continued to meet BPD criteria. Although there was a significant decrease in suicidal behaviors, neuroticism, impulsiveness, and aggression-hostility, few participants improved in occupational and social functioning (Alvarez-Tomás et al., 2017). Therefore, improving the efficacy of psychotherapeutic interventions for BPD is needed.

MDMA-assisted therapy

Given the need for effective BPD interventions, the potential of integrating psychedelics within such interventions has become noteworthy. MDMA is a subset of psychedelics, which are pharmacological agents that induce non-ordinary states of consciousness and affect individuals' mood, cognition, and perception (dos Santos, Osorio, Crippa, & Hallak, 2016). Serotonergic psychedelics, which include lysergic acid diethylamide (LSD), psilocybin, and dimethyltryptamine (DMT), share a common primary mechanism of action via agonism of serotonin 5-HT 2A receptors (Nichols, 2016). MDMA is often considered an entactogen due to its ability to induce feelings of interpersonal closeness and empathy (Bershad et al., 2019). MDMA's mechanisms of action include increased levels of oxytocin, serotonin, norepinephrine, and dopamine (Sessa, Higbed, & Nutt, 2019). MDMA-AT takes a total of two sessions over a period of 12 weeks (Vermetten & Yehuda, 2020), compared to traditional BPD treatment that takes an average of one to three years (Biskin, 2015). There are no BPD-specific drug treatments, but many of the medications include antidepressants, antipsychotics, mood stabilizers, and anxiolytics (Mier et al., 2012). When taken by mouth, effects begin within 30–45 min and last 3–6 h. The patient experiences non-ordinary forms of consciousness such as those experienced in meditation, near-death experiences, and mystical experiences, as well as the phenomenon of ego dissolution (Freye, 2009).

MDMA-AT involves incorporating 3,4-methyl​enedioxy​methamphetamine to catalyze the therapeutic process. To date, it has been heavily studied in the treatment of PTSD patients. The treatment model combines biological and psychotherapeutic approaches synergistically, expediting trauma processing. MDMA reduces the patient's fear response, providing access to traumatic memories, and creating an empathic and genuine emotional experience. According to fMRI scans in healthy volunteers, MDMA decreases activity in the left amygdala significantly. Reduction in stress-induced activation of the amygdala is also enhanced by empathic interaction with the therapists during and after the patient's MDMA experience. By diminishing the fear response, the patient decreases their defensiveness, which provides access to memories and enhances the identification of and response to emotional states through empathic, supportive treatment (Carhart-Harris et al., 2014).

In 2017, MDMA-AT was granted breakthrough expanded access therapy status by the FDA, indicating that there is preliminary evidence that MDMA-AT offers a substantial improvement over other options for serious health conditions (Mithoefer, Wagner, Mithoefer, Jerome, & Doblin, 2011). MAPS reported a series of six phase II clinical trials looking at MDMA-AT for PTSD. Participants met DSM-4-R criteria for a diagnosis of PTSD and were treatment-resistant to at least three months of antidepressant treatment in addition to at least six months of psychotherapy. Participants were given preparatory, non-drug psychotherapy; two or three 8-h MDMA-assisted psychotherapy sessions; and follow-up non-drug psychotherapy sessions (Mithoefer et al., 2011).

Jerome et al. (2020) conducted a study involving 107 participants to investigate the impacts of MDMA-assisted psychotherapy on psychological trauma and long-term remission, assessing outcomes up to six years after the intervention. No drug-related adverse events or neurocognitive effects were observed. Despite participants suffering from chronic, treatment-resistant PTSD for an average of 17.8 years, promising results were noted. At the primary endpoint, 53% of participants in the active dose groups (75–125 mg) did not meet the criteria for PTSD according to the Clinician-Administered PTSD Scale-4 (CAPS-4), compared to 23% in the control groups (0–40 mg). Two months post three sessions of MDMA-assisted psychotherapy, 61% of participants no longer met the criteria for a PTSD diagnosis, increasing to 67% at the one-year follow-up. Remarkably, the percentage of participants reporting suicidal ideation decreased from approximately 60%–24% after one year.

MAPS and the FDA agreed on the design for Phase III trials, and it was approved in early 2021. The Phase III trials were the first randomized, double-blind, placebo-controlled trials in 90 participants with severe PTSD. Participants received three sessions with MDMA (80–120 mg) and an additional half-dose after 1.5–2 h, or placebo combined with three preparatory and nine integrative therapy sessions. Drug safety was considered by assessing the patient's heart rate, blood pressure, and body temperature while being cognizant of any signs of adverse events and suicidal thoughts. Common side effects were transient, mild to moderate in severity, and included decreased appetite, muscle tightness, and hyperhidrosis (Mitchell et al., 2021).

Phase III data indicates that MDMA-AT is highly efficacious in individuals with a treatment-resistant PTSD diagnosis and is safe and well-tolerated, even in those with comorbidities. The first Phase III trial induced robust attenuation in CAPS-5 Total Severity Score (MDMA -24.4 points vs. placebo −13.9) and significantly decreased the SDS total score (MDMA change −3.1 vs. placebo change −2.0; Mitchell et al., 2021). Phase II trials revealed that 54% of the study participants no longer met the PTSD diagnosis compared to 23% in the control group. Furthermore, benefits continued to improve long term; a year later, the number of participants who no longer met the PTSD criteria had risen to 68% (Mithoefer et al., 2019). In the final Phase III trials, Mitchell et al. (2023) reported that 71% of participants no longer met the criteria for PTSD, and 46.2% met the criteria for remission of PTSD at the primary study endpoint.

During an era where new treatments for PTSD are so desperately needed, MDMA represents a potential breakthrough treatment that merits expedited clinical development. If MDMA-AT is FDA approved, decisions will need to be made on physician qualifications to prescribe and administer MDMA, MDMA-AT site qualifications, and drug production and storage. Currently, MDMA is being researched to treat other diseases such as social anxiety for individuals diagnosed with autism, individuals diagnosed with eating disorders, individuals experiencing anxiety related to life-threatening illnesses, and those with alcohol addiction. To date, MDMA-AT has proven beneficial for various psychological trauma-related problems. No studies have been found or published on significant adverse effects of MDMA-AT. Instead, transient mild to moderate adverse events have been found (Mitchel et al., 2021).

Pharmacological impact of MDMA-AT for BPD and PTSD

Multiple receptors, neurotransmitters, and intermediary processes account for MDMA's neurobiological effects. MDMA acts as a releaser of serotonin (5-HT), noradrenaline, and dopamine (Vegting, Reneman, & Booij, 2016). Activity in the 5-HT system attenuates feelings of anxiety and depression, reduces the amygdala's fear response, increases self-confidence, closeness, self-compassion, empathy, and contributes to a positive mood such as elation (van Wel et al., 2012). Increased noradrenaline and dopamine increase arousal and awareness, motivate therapy engagement, and promote fear extinction (Sessa et al., 2019).

Oxytocin, a neighboring pituitary neuropeptide to arginine vasopressin, has grabbed the public's attention due to studies linking it from autism to orgasm. However, translational research has proven difficult, as oxytocin does not readily cross the blood-brain barrier. As an indirect inducer of oxytocin release, MDMA serves as an excellent alternative. Because of this unique property, Nardou et al. (2019) decided to use MDMA to investigate oxytocin's role in critical periods. Critical periods are developmental periods that occur during primal years in which an individual is sensitive to specific environmental stimuli required for proper organization and learning essential to survival. The closure of critical periods prohibits the brain's ability to adapt, even when optimal circumstances are created. This illustrates the high treatment non-response rates seen in BPD and PTSD. With a single dose of MDMA, adult mice were able to reopen the critical period for social reward learning via oxytocin-mediated plasticity in the nucleus accumbens. In contrast, isolated adult mice that were administered MDMA did not exhibit the reopening of their critical period. Results indicated that MDMA's effects, along with a therapeutic environment, proved efficacious for individuals with unresolved trauma related to their critical developmental periods (Nardou et al., 2019), which are notable in the BPD- PTSD population (Zanarini et al., 2007).

Oxytocin receptors have also been found throughout the cardiovascular system, mediating parasympathomimetic effects that lead to lower blood pressure, heart rate, and anti-inflammatory action. During stress or pain, individuals are neurobiologically programmed to be motivated towards social bonding, providing relief through an oxytocin-mediated negative feedback loop (Bershad et al., 2019). The oxytocin feedback loop can be underdeveloped for individuals with insecure parental attachments in childhood, certain genetic risk factors, or a combination of both (Nolte et al., 2013). When these issues are coupled with trauma, it becomes even more difficult to self-resolve an acute stress reaction, setting off a cascade of cognitions, behaviors, and affective instability that lead to the development of trauma-related disorders (Feduccia & Mithoefer, 2018) such as BPD or PTSD (Zanarini et al., 2007).

Oxytocin has emerged as the core ingredient in elucidating the mechanism of MDMA's effects in PTSD. Effects on limbic brain circuitry, brain-derived neurotrophic factor (BDNF), monoamine release, and serotonin release are all intimately intertwined as well. According to the serotonin hypothesis, MDMA has been inextricably linked with mood, happiness, and ecstasy. Patients with BPD and PTSD have an amplified and uncontrolled response from the amygdala to attachment-injury scripts and trauma-specific cues (Ford & Courtois, 2014). Serotonin helps regulate mood, while oxytocin increases trust, emotional awareness, and levels of empathy and closeness (Sessa et al., 2019), and reduces the amygdala's response. The effect is reduced anxiety and hypervigilance and heightened states of consciousness (Yazar‐Klosinski & Mithoefer, 2017). Moreover, fMRI brain imaging studies showed reduced amygdala activity and increased blood flow to the occipital cortex and ventromedial prefrontal cortex.

Neurochemically, MDMA activates 5-HT serotonin receptors and alpha-2 receptors. This increases sedation and relaxation, which is hypothesized to be conducive in addressing trauma-induced hypervigilance. These effects promote memory reconsolidation by helping the patient access traumatic memories while they are feeling detached from the sense of imminent threat (Feduccia & Duvauchelle, 2008).

MDMA's effects on alpha-2 receptors contribute to the drug's effects on thermoregulation and may also contribute to a paradoxical relaxation/sedation effect (Bexis & Docherty, 2005), which could be beneficial in the context of trauma-induced hypervigilance (Amad, Ramoz, Peyre, Thomas, & Gorwood, 2019). In animal studies, MDMA increases elevated levels of brain-derived neurotrophic factor (BDNF) in the amygdala, which aids in fear extinction. These levels may account for the observed phenomenon where the patient safely recalls painful emotional memories that they usually avoid due to overwhelming discomfort. Increased prosocial feelings, improved tolerance for addressing negative memories, and enhanced levels of empathy and self-compassion promote a strong therapeutic alliance and help the patient effectively process traumatic memories (Sessa et al., 2019).

Treatment for BPD

Psychotherapy is the first-line treatment for a BPD diagnosis. BPD psychotherapy fundamentally consists of individual patient sessions or sessions in a group setting with a mental health clinician (Gunderson et al., 2000). Medications are currently not FDA-approved to treat the underlying etiology of BPD, but they do help with associated symptoms such as depression, anxiety, or psychosis (Linehan, 2016). Often, BPD patients with severe depression need an antidepressant medication to give them the energy and cognitive ability for therapy. Mood stabilizing medications such as Lamotrigine have been shown to address the impulsivity and aggression in BPD (Ripoll, 2013). In a recent study, it was found that Ziprasidone, an atypical antipsychotic medication usually used to treat schizophrenia as well as acute mania and mixed states associated with bipolar disorder, can relieve depression and delusional symptoms in moderate-high clinically severe BPD patients. Off label, Ziprasidone is also used for depression, bipolar maintenance, and post-traumatic stress disorder (Pascual et al., 2004). This provides evidence that medication cannot solve the personality disorder but can aid in the healing process.

First-line psychotherapy treatment for BPD is a third-wave treatment of cognitive behavioral therapy known as dialectical behavior therapy (DBT). DBT has been shown to reduce the need for medications and medical care by up to 90% (Linehan, Dimeff, Koerner, & Miga, 2014). DBT utilizes mindfulness, distress tolerance, interpersonal effectiveness, and emotional regulation to reduce self-destructive behaviors by teaching the patient skills for regulating their emotions and creating healthy attachments in interpersonal relationships (Linehan, 2016). Traditional DBT treatment has four components: skills training group, individual psychotherapy, telephone consultations, and therapist consultations (Linehan et al., 2014). Treatment goals are designed to manage or reduce life-threatening behaviors and improve occupational and social functioning (Linehan, 2016).

Methods

Interviewing two BPD-specialized treatment providers and two MDMA-AT-specialized clinicians was one way to examine the phenomenology of MDMA-AT with BPD individuals in a thoughtful manner. By capturing four clinicians' perspectives of MDMA-AT and BPD, the study increased our understanding of the underlying therapeutic mechanisms and processes and the role of pharmacological factors in these treatment modalities, optimizing treatment context, and leading to improved clinical responses and patient recovery.

This study hoped to share experiences on what potential impact MDMA-AT has on the BPD population according to clinicians' perceptions and how current treatment modalities compare. The participants were drawn from two primary groups: DBT clinics and MDMA-AT clinics sponsored by MAPS. One group was contacted by experts in DBT via consultation with past supervisors. The other group was contacted by experts in MDMA-AT via consultation with MAPS-affiliated clinicians. This qualitative research focused on a difference in conceptualization and attempted to identify different mechanisms of change and interventions from current theories of BPD and its treatment. The research is designed to support future generations of more provisional models and potential grounded theories for working with BPD patients.

This study attempted to describe experiences and perceptions of working with individuals diagnosed with BPD from the perspective of two clinicians who specialize in treating patients diagnosed with BPD and two clinicians who treat patients using MDMA-AT through case study research. The results involve a discussion of themes and patterns. At this research stage, the central concept being studied is defined as clinicians' perspective of MDMA-AT as a potential treatment for patients with BPD.

Research questions

The study's overall research question was: “What is the phenomenology of MDMA-AT for treating patients with BPD?” Some research questions explored were:

  1. What are your perspectives of the current treatment modalities for BPD patients?

  2. What are your perspectives of MDMA-AT treatment?

  3. What fosters the utilization for treatment for BPD?

  4. What do you see as barriers for MDMA-AT treatment for BPD?

  5. What fosters the utilization MDMA-AT for BPD?

  6. What are some challenges you foresee in MDMA-AT treatment for BPD?

  7. Please describe your perception on how MDMA-AT would impact the BPD population.

Preliminary data analysis

After transcribing the interviews, the PI met with members of the research team to discuss initial themes for the data. Upon completing seven revisions of the initial domains, the PI came to consensus on the final three domains. The domains were named: Phase 1: Emotional and Behavioral Safety, Phase 2: MDMA-AT, Phase 3: Life Worth Living.

During this part of the coding process, the PI met with the research team to discuss the first interview. Members of the team came to consensus through discussion on multiple points and adjusted some of the themes in order to capture the participant's emic experience. The team also provided areas of exploration in order to address the research question and illustrate a more accurate emic experience in the second interview. The team met again and agreed on the coding procedures. The consensus process lasted between 1 and 4 h at each meeting. At this point, the PI agreed that the names of the domains were the best reflection of the data and decided to maintain the aforementioned domains.

Next, all the codes within the interview data were labeled according to one of the three domains. The PI brainstormed possible core ideas for the domains, read through each domain, and applied core ideas to the data. These core ideas were discussed and clarified with the research team and agreement was reached on the strategy for naming of the core ideas through peer examination. From there, the PI created consensus drafts of all interviews that were categorized by domain and core idea. The PI then began to examine each core idea for categories, nuggets, or threads of common or unique experience across the interviews. Next, the initial domains, core ideas, and categories were shared with the peer examiner, who reviewed the information and listened to the researcher's description of the initial categories after reading through the purpose of the study, the interview protocol, and the interviews. After the initial writeup of the results section, it was decided that the themes that were initially developed did not capture the depth of the data and another code system with DBT/MDMA-AT overlap was necessary. Therefore, the data were reanalyzed by the PI, with guidance from the feedback provided by the peer examiner and study advisor. The final analysis resulted in three domains: Phase 1: Emotional and Behavioral Safety; Phase 2: MDMA-AT; Phase 3: Life Worth Living.

Before the results were presented to the participants, the criteria for evaluating the analysis were explored. Transparency of methodology supported the reader's evaluation of the actions of the PI and research team. The team revisited biases throughout the research process. The researcher also discussed her noted reactions from the interviews within the field journal with her peer examiner. These measures were used to support the validity of the data. The PI began generating a narrative to discuss preliminary findings with participants between the first and second interviews and following the second interview. The participants were encouraged to share thoughts, concerns, and areas to edit so that the data was accurate to their emic experience. The participants confirmed that the data was accurate and that it captured their emic experience.

Results

This qualitative study addressed my overall research question: “What is the phenomenology of MDMA-AT for treating patients with BPD?” The analysis of this research question yielded four core domains. The results are organized first by core domain, second by core idea, and lastly by category. Data is grouped first by core domain. The core ideas attempt to categorize smaller nuances of information within the domains. The categories highlight unique components of participant experience within each domain. The frequency at which these categories occur in the sample was taken into account. In this study of four participants and eight interviews, categories that occur between one to five incidences are considered rare, between 6 and 10 are moderate, and 11–100 are significant.

Narrative generation

This study's results emphasized patterns that create narratives to make sense of the phenomenology of MDMA-AT for treatment of BPD individuals. The codes generated unique perspectives of the participants revealing their emic experiences, which were organized by the PI into a chronological narrative that included three phases of treatment. Direct interview quotes are used to highlight and personalize the data. The quotes have been edited for grammatical clarity and all identifying information has been omitted to protect participants' identities.

Treatment phases

Phase 1: Emotional and behavioral safety (dialectical behavioral therapy)

Clinicians described that a three-phase treatment would be necessary to address limitations that each treatment provides to ensure safety and efficacy for the patient. In Phase 1, DBT addresses emotional and behavioral concerns. DBT is a structured, goal-oriented, cognitive-behavioral-based treatment for emotional dysregulation.

Eligibility stemming from emotion dysregulation:

As far as the DBT program, you basically got to have some emotion dysregulation going on; that’s really kind of what we're looking for.

-DBT clinician

DBT clinicians expressed that patient fitness is an integral part of treatment prognosis. Commitment/motivation for treatment (to be willing to change), goal-oriented, moderate insight level, acceptance of reality, ability to be vulnerable, and adherence to boundaries and treatment rules (no suicide/self-harm) are positive prognostic indicators.

DBT treatment is excruciating, commitment to change is hard:

I think they’re working so hard all the time. It is excruciating for a lot of the time to do this work. Right? Because it expects expectations of being very vulnerable, to face a lot of things that they’re really ashamed of. One of the harder things is change. I mean we’re really pushing for change all the time.

-DBT clinician

Commitment to a life worth living:

So, what I’ll say to them is, “If we're going to work together, you can’t kill yourself.” And sometimes they kind of laugh a little. And I’m like, “No, this isn't some liability thing or we’re doing safety planning. The reason you can’t kill yourself is because, have you ever been in a job or relationship you knew you’re leaving? It’s pretty tough to do the work when you keep looking at the door. So, if you were immortal what would you have to do?” And they almost always say, “I’d have to fix my shit.” “Right, that’s why you can’t kill yourself. Because if you keep looking at the door, you’re not going to want to do the hard work.”

-DBT clinician

Boundary setting:

Discussed explicitly from sort of the beginning of therapy, which is to say, “Hey, there’s some things, this is the way I do it here, what’s okay with me and not okay with me, if somehow you end up doing something that I experience is crossing my limits, then we’ll talk about it, and similarly with you.” And so that's the kind of boundary setting, limit side. And on the sort of fostering of the relationship there's a lot of explicit expressions of warmth and affection and caring that do occur in the relationship from the get-go.

-DBT clinician

The cornerstone of treatment involves skill building via individual and group therapy sessions. Skill building encompasses the following areas: radical acceptance, interpersonal effectiveness, acceptance and change, emotion regulation, understanding cognitive distortions, wise mind, mindfulness, self-efficacy, understanding emotions and validating emotions, and distress tolerance skills.

DBT treatment is divided into four stages: pre-treatment (identifying goals, psychoeducation on DBT, commitment to reducing suicide/self-harm behaviors, commitment to treatment), stage 2 (commitment safety and stability, life-threatening behaviors, therapy-interfering behaviors, quality of life interfering behaviors), stage 2 symptom reduction (trauma processing, SUDS, eating disorders, anxiety disorders, mood disorders), and stage 3 (regulating emotions through acceptance and change, chronic sense of emptiness, interpersonal relationship difficulties, inadequate quality of life). Each stage moves the patient from “living in hell” to a “life worth living.”

Resolving externalizing behaviors:

Behaviors that you tend to see resolve over time are behaviors that are a little more externalizing and tend to actually resolve the quickest are the externalizing behaviors.

-DBT clinician

Understanding emotions, identifying cognitive distortions, and regulating emotions:

We added into the section on emotion regulation, which is all about understanding emotions, understanding how they work, understanding how they affect you. We add it in because that’s often where you’re going to get the distortions, so the facts are this, then there’s our interpretation of it, and based on our patients' histories, their interpretation is often slightly distorted.

-DBT clinician

Stages of DBT:

So, stage one is about getting out of hell, but it’s really like getting out of that constant crisis generation, and cycle of in and out of the hospital. And so, you’re really getting behaviors under control, you’re loading them up on skills…Stage two is really getting at a lot of times quality of life behaviors, so depression, anxiety, PTSD, interpersonal problems, substance use, things like that, things that have been getting in the way for a long time. And you might find that it looks somewhat close to other treatments like CBT. Or, it’s a behavioral approach, you’ll still keep some of the same ingredients from stage one like the diary card, and there’s still these skills focused for sure, but it’s less on skills acquisition, more on skills generalization. Less on less getting things to just calm down and more like, okay can you now go live your life and actually start to start to address these problems that cause this whole thing to begin with. From there, there’s stage three, there’s stage four, that starts five. From there, you’re moving more into problems of daily living, and things like finding self-actualization, and connection, and things like that. I tend to see clients more stage one and stage two.

-DBT clinician

DBT clinicians also have valuable roles which include adherence to the DBT manual, providing support through acceptance and change, upholding, and explicitly discussing boundaries, coaching/crisis calls, grounding the treatment in reality (especially during hyper-arousal symptoms of dissociation), teaching and modeling skills, and consulting weekly with other DBT clinicians. They described how treating the BPD population comes with a lot of stigma from the mental health field and find the lack of treatment and support frustrating.

Treatment team, supervision, and competencies/qualities as a DBT clinician:

A therapist’s qualities that can help is somebody who’s well trained, honestly. A big piece of it is getting really good training in DBT and supervision in DBT. You need to have a team. That’s part of the requirement of being a DBT therapist; you have a DBT team. And as far as qualities, I’ve seen so many different types of DBT therapists it would be hard for me to say that one is like a particular quality, but a commitment to the treatment and a commitment to doing what works, and the commitment to helping a person get to their life worth living is really important. And what comes with that is willing to almost like take risks in therapy that you might feel afraid to do otherwise.

-DBT clinician

Ability to tolerate suicidality and self-harm:

I think when they start to self-harm that is going to freak out most therapists understandably. Like, if you don’t live in this world, that seems like some really extreme stuff, and how do you separate self-harm from was it a suicide attempt, and how suicidal are they? And that’s kind of what makes DBT therapists different is because we live in this world, we can tolerate it better.

-DBT clinician

Stigma against BPD individuals in the field of psychology, lack of treatment:

I cannot express how disappointed I am in the field of psychology with their view of borderline. If you haven’t experienced it yet, you will. You will be at a conference, someone will get up and they’ll talk, they’ll say ‘I have a patient who’s borderline’, and hear this sigh in the crowd. Most people in psychology have no idea what they’re talking about, and they have a terrible view of them. That’s, that’s my real biggest beef. I mean the thing about joining us, right? 14 years, we’ve got no one to join us. That’s just crazy, right? And then when I talk to people because I know other people, “Hey, what do you think [about] joining us?” “Ah, you know those borderlines.” If it was a race, it would be racism, right? Imagine someone saying, “Ah, you know working with those Asians they're so hard.” People would be like, “What?” Working with borderlines, people are just like “Oh yeah, it’s okay because you know they are crazy.”

-DBT clinician

Building therapeutic rapport, relationship of equals, explicitly setting limits:

In DBT, as much as possible, this is a relationship of equals. And so maybe traditional therapeutic relationships there would be a more explicit power differential that you might feel with the therapist themselves being quite blank or not disclosing too much, the patient on the other hand being the one who does all of that. And this isn’t to say that’s not how it is in in therapy and DBT therapy, but the explicit emphasis is a little bit more on it being equals and for that both the fostering of the relationship as well as limit setting, I think goes with that… And then the other piece I guess that would probably foster that sort of connection is the focus on validation and acceptance really. It’s really trying to get at it from a place of I really want to understand what’s going on for you, and exactly how you feel it, and exactly how you experience it. And I do think that that makes a really big difference in terms of the building of the relationship.

-DBT clinician

Phase 2: MDMA-assisted therapy

MDMA-AT induces non-ordinary states of consciousness that take individuals from cognitive awareness to an embodiment. MDMA-AT deepens the awareness and healing from past trauma; builds cohesion with self, self-other, and self-world; and promotes spiritual fulfillment, something that remains unresolved through DBT treatment. Positive prognostic indicators include individuals who completed DBT Stage 1 treatment and can apply emotion regulation skills, no longer exhibit self-harming behaviors, can regulate intense emotions, have a cohesive, non-fragmented sense of self, understand and practice mind-body integration work, are grounded in reality (low dissociation and distortions of reality symptoms), and have supportive relationships with others.

Client fitness and readiness for MDMA-AT, trust in the therapy and clinicians, trust in their; skills to self-regulate:

The clients have to have an understanding and obviously a willingness, right? And also, that we’ve ruled out the probability of any kind of psychotic reaction, or any type of serotonergic crash, so we know that’s already off the table. But in terms of the person psychologically, they have, um, you know, they have awareness of the resources within themselves that they can tap into. So, just in terms of exploring experiences where a person may have been confronted with a lot of fear, how did they establish some sense of self-efficacy over that, or some mastery with that? When I know that they’re refamiliarized with those aspects of themselves that promote some ego strength, then I know that they’re prepared. And also, it’s more of an intuitive thing, I’m in touch with their trust in me and their confidence in me and the co-therapist. So that they can relax into the experience. So, they know that they’re gonna be held in this and they’re comfortable with that. And also, when they have an understanding, like some educational aspects of MDMA, so they are aware that they are always in control and they’re confident that this is a good way to go forward. And those are the kinds of things that I look for to say, “Okay, this person, is this person prepared for the medicine?”

-MDMA-AT clinician

Due diligence for patient readiness:

Due diligence in creating a sense of this person can manage this. I would definitely have the support system for that patient on board with the very big picture. So, you know, both pre-medicine visit post medicine visits. And it would really depend how well functioning the borderline diagnosis person is.

-MDMA-AT clinician

MDMA-AT's ability to hold space for pain to be processed and build a new narrative:

MDMA helps the individual create a new narrative. And in creating a new narrative, the coping skill of any type of self-harm behavior, like “I can’t handle it anymore; I got to jump off the cliff now”; hopefully with, you know, the right work in that direction, the person's response flexibility improves. So, there is not that total black and white, good or bad, all or nothing, and I gotta end it because nothing is ever going to be any different. With MDMA, physiologically, we change the way people can understand how they can self-regulate. And give them different types of tools to recreate that physiological experience in their system. Where they reduce their cortisol levels, stop and give themselves some space to hold their pain, and that the pain is transient, you know? So, it’s a risk. I mean that’s part of the biggest risk I think in working with these folks, and that’s why we don't want them to decompensate. So, all of those skills can be rehearsed, can be the first line of coping, rather than where’s the scissors, or the drugs,

-MDMA-AT clinician

MDMA-AT is most effective in helping patients look inward and reexamine interpersonal and self-relationships. Within the experimental session, there is: an immediacy in processing painful experiences, understanding their relationships, and their role; an emotional acceptance and understanding of past relationships and traumatic experiences; an addressing of purpose for living and fulfillment (addresses emptiness and shame/guilt); and a strengthening of the connection between mind, body, and world (nature and others). The therapy's theoretical orientation stems from the idea that although planning and mapping the treatment beforehand is integrated into the experimental session, what the MDMA will induce to be explored is ultimately unpredictable, and rather, it is believed that “inner healing intelligence” or the patient's innate inner wisdom and power will be able to overcome whatever the medicine brings up to be healed.

Balancing inner healing intelligence and mapping treatment:

And that’s where, you know, MAPS’ idea of the inner healing intelligence does work, and doesn't, because that goes both ways. In one way, people go to the place that’s hurting them and that might not be where I think we should start, like you know they’re into number three or four. For example, this person who I just started to work with, she had some deeper traumas. She had a really bad car accident and had real trauma from it. And I said in our first session I think you should try to stay with the car accident in which she had a lot of startle around it. But in her [MDMA] session she literally went into her own birth trauma, I mean, you know, she was she was like she’d never heard of this, but she was like she had read the playbook and she just went right into it. The point about that is you can map out how you want things to go, but then how things go depends on what people are ready for. You know, most of the time that’s okay, sometimes people go into things that they really are not ready to manage, and they come out of the sessions really raw and needing quite a bit of assistance to manage what came up for them.

-MDMA-AT clinician

Reverence for MDMA:

The medicine is smarter than both of those therapists in the room put together.

-MDMA-AT clinician

Building coherence with “frozen” parts of the self:

What part of what fragments the self is freeze. That under conditions of threat people have come to have come to freeze. And then that part of them gets compartmentalized off, you know. And if that happens enough then, you know, there’s a whole bunch of different frozen parts. And the medicine can start to thaw all of that.

-MDMA-AT clinician

This “inner healing intelligence” creates a different role for the MDMA-AT clinician, as the clinician must be trusted by the patient to provide support and structure for them to heal what comes up for them during the experimental session. This also includes being able to regulate adverse events such as self-harming behaviors through support, creating a peaceful inpatient setting, and monitoring adverse physiological reactions (monitoring blood pressure, liquid intake, dosing, concomitant medications, etc.).

The importance of embodiment and mentalization in treatment with personality disorder patients:

So, part of what the medicine ends up doing is actually reinforcing embodiment and mentalization. Because if someone is more embodied, they’re able to mentalize. Then the less severe their character disorder is. Now you’re starting to get into, you know, once somebody can start to talk about “This [is] what I can feel in my body, and this is what it brings up for me,” you’re getting out of, you know, the acting out character. You know you’re getting into the neurotic character.

-MDMA-AT clinician

The MDMA-AT clinician's role is of an observer, providing empathy, non-direction, and support. A trust is established that MDMA will help the patient resolve past traumatic experiences, attachment/developmental injuries, etc. through their “inner healing intelligence.” The clinician is there to provide a safe and supportive environment through methodically planning for possible decompensation by mapping the treatment in pre-MDMA sessions from the least emotionally intense to the most emotionally intense in order to allow the patient to develop skills for processing the least severe to most severe traumatic experiences.

Body is a guide to healing trauma stored in the body:

It provided us with a guide like you had mentioned earlier; the body kind of gives us those insights. When we’re in touch with that somatic stuff, we have a guide to another level or layer of how to work with the trauma.

-MDMA-AT clinician

Self as a traumatized entity:

So, it’s really the self is a trauma is a traumatized entity. It’s a shattered self and there’s compromises that get built on top of that so that people can carve out some kind of functioning.

-MDMA-AT clinician

The MDMA-AT clinicians also expressed that, unlike with traditional treatment modalities, MDMA-AT clinicians must have a reverence for the medication and trust that what is induced is a vital part of the healing phenomenon. Yet, the MDMA-AT clinicians must also display some comfort and ability in trauma-processing, emotional dysregulation, suicidality/self-harm, and addressing projection-identification. Techniques that the MDMA-AT clinician utilizes throughout the experimental session are redirection to the self, pacing (breath work), awareness of the bodily reactions that arise as trauma is exhibited somatically, and the integration of an environment with the self via eye shades, music, scents, etc. It is important for the clinician to not interfere with the patient's processing, but rather to guide the patient to process what comes up for them during the experimental session by going back inside themselves.

MDMA-AT therapist describes prognosis for treatment:

The people with the most preparation, and that's generally people I’ve worked with for a while have, 1. They have a pretty good map of what’s happened to them in their lives, their relationship with their parents, and their families growing up, and how that’s affected them. 2. They’ve all participated in things like yoga and massage and other forms of body work that help them to be more grounded in their body and get better information from their body. 3. They’ve all participated in mindfulness practice and so they have sort of a ready to reflect on their experience.

-MDMA-AT clinician

Sense of embodiment the medicine is able to induce:

It’s one thing to know that from the standpoint of you know sort of remembering it and talking about it as a cognitive construct. But that’s not what happens on MDMA; it comes up as it was experienced. And then knowing is an embodied knowing.

-MDMA-AT clinician

MDMA creating sense of safety and well-being:

It just melts away years of therapy. And provides that container for patients to feel safe and secure in their own skin. And in their own sense of well-being, and safety, for them to navigate that part of their trauma and emotional and psychological geography, where it was too scary to go prior to the introduction of this medicine.

-MDMA-AT clinician

Support was also expressed frequently to address patient safety. Both “set” (mindset) and “setting” (environment) of MDMA-AT matters, and treatment is most effective where patients and clinicians feel comfortable and honor the medication process. The clinicians described how treatment conducive to healing would be in a homey inpatient setting where the patient would be monitored before, during, and after drug sessions for an extended period; there would be more pre-MDMA and post-MDMA therapy sessions; and there would be some integration or focus on a positive support network (parents, significant others, etc.).

Post-MDMA, creating a caring environment for the patient to recover:

Basically, like taking someone under your complete care like you would a small child to help them recover.

-MDMA-AT clinician

Inpatient setting to support the healing process and to keep the BPD patient safe:

YES. Yes, it would have to be one. An inpatient or home-like setting where people were allowed to regress as much as they need to regress. It would have to be developmentally informed staff that understood that this these are regressive states that need to need to be responded to. Both in terms of support and in terms of limits.

-MDMA-AT clinician

A treatment team to keep the patient's healing conducive to integration and healing:

A team beyond two therapists, if you’re using the current model of MDMA-AT, because you need a team for support as the integration process takes place, because you do want it to be an integration process, right, you don’t want it to be a disintegration process.

-MDMA-AT clinician

Phase 3: embodiment of a life worth living

Goals in DBT are hierarchical, ultimately leading towards a life worth living. When a patient can live a life worth living, they are able to effectively practice core DBT skills: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. However, post-treatment issues included a chronic sense of emptiness and moderate levels of shame and guilt. MDMA-AT treatment seeks to resolve these symptoms and more by inducing embodiment of self-compassion, mindfulness, mind-body connection, and self-awareness. Patients facilitate their own healing and embody a sense of joy, freedom, fulfillment, spiritual awareness, and acceptance. They experience a stable and coherent self-identity, positive self-worth, and purpose for living. They also experience a cohesion with self and others (sense of connectedness to self, others, and a greater whole). They move from a chronic sense of emptiness to wholeness spiritually and physically. They feel an expansion of fulfilling their own potential and contributing to a purpose greater than the self in their life.

They get catharsis from blame and shame to acceptance, peace, and gratitude:

90% of people would one of the first things out of their mouth would be, I’ve never felt so at peace in my whole life. I have never felt so comfortable in my own skin. I’ve never seen how hard I’ve been on myself. And people would be having a bit of a catharsis during that time. But there was this melting away of the defense of anger and the defense of blame and shame and when that starts to soften up, the connection between the therapists and the individual, it’s a whole different kettle of fish…it’s a deep sense of gratitude that I was willing to support them while they went through this, right?

-MDMA-AT clinician

Reality acceptance:

A huge part of DBT which is reality acceptance, which is everything, is exactly how it’s supposed to be.

-DBT clinician

Able to accept painful experiences without defense mechanisms:

Her dad’s illness, he did well for a long time, but he just got sicker and sicker over time. And so, she started to face that her dad was going to die and she was terrified of that. And she was just literally saying I’m going to kill myself once my dad dies. So, in subsequent sessions, she had three more sessions after the first, we were focused on her relationship with her dad and his illness and his impending decline and death. And then she subsequently had many conversations with him about things that they missed together and things that they weren’t able to do together. And [when] he died, she really felt she had made peace with him. She was able to take time off from work and be there and really work with saying goodbye to him and working things out with him. I think that was very powerful. In the past, she would have been extremely reactive to that. Likely would have interrupted it and wouldn't have allowed him to do it. And she was just able to participate in a mature and accepting and loving way.

-MDMA-AT clinician

Able to live their life fully:

Someone that’s coming in working on themselves, it’s sort of all inside their head, and then they go out back out and kind of do their life.

-DBT clinician

Discussion

This study intended to explore the phenomenology of MDMA-AT for treating patients with BPD. To date, there is no literature on MDMA-AT or any psychedelic assisted therapy for BPD treatment. The main themes identified by the participants were in discussed as a 3-phase protocol of treatment.

The findings from eight interviews with four mental health clinicians resulted in themes regarding individuals diagnosed with BPD experiencing great difficulties in emotion dysregulation stemming from traumatic emotional invalidation; unstable relationship patterns; feelings of emptiness, shame, and guilt; distress tolerance; mind-body connection; and a shattered sense of self. The perception of recovery expressed by clinicians treating individuals who struggle with emotional dysregulation was described as an open-ended journey that involves learning skills to cope with emotions, building healthy connections interpersonally and within the self (mind-body), and developing a fulfilling life while still reflecting on past traumatic events. Treatment was described as an intensive process, including maintaining boundaries, skills coaching, supportive care outside of therapy, creating a supportive treatment team, tolerance for handling suicidality/self-harming behaviors, and stigma surrounding the diagnosis.

Results indicate that safe and effective treatment to address trauma-related to emotional dysregulation, attachment injuries, and emptiness includes three phases. The three-phase approach begins with completing DBT treatment to resolve emotional dysregulation Stage 1 criteria (Phase 1); MDMA-AT to resolve lingering emptiness, shame, and guilt (Phase 2); and, lastly, to allow the unfolding of the healing process to occur with continued support and integration therapy sessions (Phase 3).

Clinical implications of this study

There are no studies regarding the safety and tolerability of MDMA-AT for BPD individuals, as past MDMA-AT trials have excluded BPD individuals due to their high-risk behavior (Palhano-Fontes et al., 2019). This study reinforced the need for further research on MDMA-AT treatment for BPD individuals. It suggests that MDMA-AT is safe when administered within controlled environments after careful screening and successful DBT Stage 1 treatment outcomes. The primary issue related to MDMA-AT administration for BPD is the potential for challenging psychological experiences (e.g., shattered sense of self, suicidal ideation, distress intolerance). Safety concerns related to the administration of MDMA include its ability to induce a non-ordinary state of consciousness. Given the association between BPD and suicidal behaviors, any potential safety risks must be minimized. Safety concerns can be managed through DBT stage 1 completion, MDMA-AT patient screening, inpatient session monitoring, and thorough integration follow-up care. Furthermore, participants indicated that for MDMA-AT for BPD individuals to occur safely, it would need to be (a) within controlled settings where safety can be ensured during the experimental and integration sessions, (b) in the presence of a trusted treatment provider, (c) within a peaceful, comfortable environment, and (d) where preparation and integration sessions before and following administration of MDMA-AT are provided.

Limitations of the study

Although this is the first qualitative study exploring the phenomenology of MDMA-AT for individuals diagnosed with BPD, the study size was small (n = 4). Additionally, participants were self-selected by recommendations within relatively small psychological associations that are often biased towards positive outcomes. Research in the field of highly stigmatized treatments or populations in any new research topics including these topics may overvalue positive aspects of these treatments. All participants in the present study were mental health clinicians providing potential hypotheses on the impact of MDMA-AT in working with BPD individuals. There is a need for more knowledge on the lived experiences to address this while considering safety issues that may arise with a not yet FDA-approved treatment for a vulnerable population.

It would be beneficial to replicate this study in the future to add to the validity and transferability of the findings as this is the first qualitative study exploring the phenomenology of MDMA-AT for treating individuals diagnosed with BPD. Future studies that include a larger study size with a more diverse population of clinicians would be beneficial to continue exploring this phenomenon. Future studies could also look towards including BPD individuals utilizing the MDMA-AT framework. Therefore, to determine the safety, tolerability, and clinical utility of incorporating MDMA-AT for BPD individuals, future research should aim to (a) establish safety and tolerability; (b) explore the impact of MDMA-AT on behavioral/emotion dysregulation, disturbances in self-identity, and social functioning among individuals with BPD; and (c) determine whether incorporating MDMA-AT within interventions for BPD improves treatment outcomes. Until such studies have been conducted, caution surrounding MDMA-AT administration to individuals with BPD is strongly recommended.

A critical barrier to conducting research with MDMA-AT is federal regulations (Nutt et al., 2013) that currently classify MDMA as a Schedule 1 drug. Nonetheless, approval for conducting clinical research with MDMA-AT has been granted for numerous psychiatric disorders under the FDA's breakthrough therapy designation. Despite its challenges, conducting research with MDMA-AT appears possible and could ultimately contribute to improving BPD interventions.

Conclusion

There is currently no direct research on BPD individuals using MDMA-AT, as they were excluded from studies due to high-risk behaviors. This study revealed several therapeutic processes that contribute to meaningful treatment outcomes for individuals diagnosed with BPD. It is vital to acknowledge that MDMA-AT is not FDA approved, and previous studies discussing the treatment have excluded the BPD population. Furthermore, individuals diagnosed with BPD are both vulnerable and highly stigmatized within the general public and mental health field. Recovery for people with BPD is a gradual and intensive process, and a lack of treatment hinders various aspects of this process. This study emphasized how moving toward exploring treatment impacts can be a first step in addressing the need for care and understanding BPD recovery. Since it is not well understood how psychotherapies contribute to change, it remains essential to study these complexities more closely.

Exploring participant experiences increased our understanding of underlying therapeutic mechanisms and processes and the role of pharmacological factors in these treatment modalities, which can help optimize the treatment context and lead to improved clinical responses and patient recovery. Despite the heterogeneity of patients, this studies also suggested that, in addition to a shared phenomenology, MDMA-AT exhibits similar therapeutic processes and results in comparable outcomes. As this study demonstrated, qualitative research of MDMA-AT can contribute to distinguishing the specific features of these compounds and show potential for elucidating otherwise undiscovered implications for the treatment of BPD.

This study explored how clinicians view treatment tolerability and safety to enhance recovery. It is a hopeful first step to facilitate further exploration, research, and development of psychotherapies adapted with pharmacology to deliver routine care for this often stigmatized group. It might also ensure that treatments prioritize targets relevant to vulnerable populations and help them gain access to recovery and make meaningful changes in their lives.

Conflicts of Interest and source of funding

No competing interests. No obtained funding. No funding agency had a role in study design or conduct; data collection, management, analysis, or interpretation; manuscript preparation, review, or approval; and decision to submit the manuscript for publication.

Disclaimer

The views expressed herein are those of the authors and do not reflect the official policy or position of Alpert Medical School of Brown University, Chaminade University of Honolulu Hawaii School of Professional Psychology, Yale School of Medicine, Walter Reed National Military Medical Center, Uniformed Services University, Department of Defense, or the U.S. Government.

Acknowledgements

We thank committee member, Vilmarie Baez, PsyD. for her thoughtful comments and support. Thank you to the four study participants, each of whom was an honor to learn from. Thank you for your trust, openness, and profound perspectives.

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  • Gunderson, J., Shea, M., Skodol, A., McGlashan, T., Morey, L., Stout, R., Zanarini, M., Grilo, C., Oldham, J., & Keller, M. (2000). The collaborative longitudinal personality disorders study: Development, aims, design, and sample characteristics. Journal of Personality Disorders, 14(4), 300315. https://doi.org/10.1521/pedi.2000.14.4.300.

    • Search Google Scholar
    • Export Citation
  • Gunderson, J. G., Stout, R. L., McGlashan, T. H., Shea, M. T., Morey, L. C., Grilo, C. M., et al. (2011). Ten-year course of borderline personality disorder: Psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Archives of General Psychiatry, 68(8), 827837.

    • Search Google Scholar
    • Export Citation
  • Jerome, L., Feduccia, A., Wang, J., Hamilton, S., Yazar-Klosinski, B., Emerson, A., et al. (2020). Long-term follow-up outcomes of MDMA-assisted psychotherapy for treatment of PTSD: A longitudinal pooled analysis of six phase 2 trials. Psychopharmacology, 37(8), 24852497. https://doi.org/10.1007/s00213-020-05548-2.

    • Search Google Scholar
    • Export Citation
  • Linehan, M. (2016). DBT skills training manual for treating borderline personality disorder (2nd ed.). New York: Guilford Press.

  • Linehan, M., Dimeff, L., Koerner, K., & Miga, E. (2014). Research on dialectical behavior therapy: Summary of the data to date. http://behavioraltech.org/downloads/research-on-dbt_summary-of-data-to-date.pdf.

    • Search Google Scholar
    • Export Citation
  • Mier, D., Lis, S., Esslinger, C., Sauer, C., Hagenhoff, M., Ulferts, J., et al. (2012). Neuronal correlates of social cognition in borderline personality disorder. Social Cognitive and Affective Neuroscience Electronic Resource, 8(5), 531537. https://doi.org/10.1093/scan/nss028.

    • Search Google Scholar
    • Export Citation
  • Mitchell, J. M., Bogenschutz, M., Lilienstein, A., Harrison, C., Kleiman, S., Parker-Guilbert, K., et al. (2021). MDMA-Assisted therapy for severe PTSD: A randomized, double-blind, placebo-controlled phase 3 study. Nature Medicine, 27, 10251033. https://doi.org/10.1038/s41591-021-01336-3.

    • Search Google Scholar
    • Export Citation
  • Mitchell, J. M., Ot’alora, G. M., van der Kolk, B., et al. (2023). MDMA-Assisted therapy for moderate to severe PTSD: A randomized, placebo-controlled phase 3 trial. Nature Medicine. https://doi.org/10.1038/s41591-023-02565-4.

    • Search Google Scholar
    • Export Citation
  • Mithoefer, M., Feduccia, A., Jerome, L., Mithoefer, A., Wagner, M., Walsh, Z., et al. (2019). MDMA-Assisted psychotherapy for treatment of PTSD: Study design and rationale for phase 3 trials based on pooled analysis of six phase 2 randomized controlled trials. Psychopharmacology, 236(9), 27352745. https://doi.org/10.1007/s00213-019-05249-5.

    • Search Google Scholar
    • Export Citation
  • Mithoefer, M., Wagner, M., Mithoefer, A., Jerome, L., & Doblin, R. (2011). The safety and efficacy of {+/−}3,4-methylenedioxymethamphetamine-assisted psychotherapy in subjects with chronic, treatment-resistant posttraumatic stress disorder: The first randomized controlled pilot study. Journal of Psychopharmacology (Oxford), 25(4), 439452. https://doi.org/10.1177/0269881110378371.

    • Search Google Scholar
    • Export Citation
  • Nardou, R., Lewis, E., Rothhaas, R., Xu, R., Yang, A., Boyden, E., et al. (2019). Oxytocin-dependent reopening of a social reward learning critical period with MDMA. Nature, 569, 116120. https://doi.org/10.1038/s41586-019-1075-9.

    • Search Google Scholar
    • Export Citation
  • Nichols, D. (2016). Psychedelics - Pharmacological Reviews, 68(2), 264355. https://doi.org/10.1124/pr.115.011478.

  • Nolte, T., Bolling, D. Z., Hudac, C. M., Fonagy, P., Mayes, L., & Pelphrey, K. A. (2013). Brain mechanisms underlying the impact of attachment-related stress on social cognition. Frontiers in Human Neuroscience, 7, 816.

    • Search Google Scholar
    • Export Citation
  • Nutt, D., King, L. A., & Nichols, D. E. (2013). Effects of schedule I drug laws on neuroscience research and treatment innovation. Nature Reviews Neuroscience.

    • Search Google Scholar
    • Export Citation
  • Palhano-Fontes, F., Barreto, D., Onias, H., Andrade, K., Novaes, M., Pessoa, J., et al. (2019). Rapid antidepressant effects of the psychedelic ayahuasca in treatment-resistant depression: A randomized placebo-controlled trial. Psychological Medicine, 49, 655663. https://doi.org/10.1017/S0033291718001356.

    • Search Google Scholar
    • Export Citation
  • Pascual, J., Silvia, O., Soler, J., Barrachina, J., Álvarez, E., & Victor, P. (2004). Ziprasidone in the acute treatment of borderline personality disorder in psychiatric emergency services. The Journal of Clinical Psychiatry, 65, 12811282. https://doi.org/10.4088/JCP.v65n0918b.

    • Search Google Scholar
    • Export Citation
  • Ripoll, L. H. (2013). Psychopharmacologic treatment of borderline personality disorder. Dialogues in Clinical Neuroscience, 15(2), 213224. https://doi.org/10.31887/DCNS.2013.15.2/lripoll.

    • Search Google Scholar
    • Export Citation
  • Roepke, S., Vater, A., Preißler, S., Heekeren, H. R., & Dziobek, I. (2013). Social cognition in borderline personality disorder. The Florida Nurse, 6, 195.

    • Search Google Scholar
    • Export Citation
  • Scott, L. N., Levy, K. N., & Pincus, A. L. (2009). Adult attachment, personality traits, and borderline personality disorder features in young adults. Journal of Personality Disorders, 23(3), 258280.

    • Search Google Scholar
    • Export Citation
  • Sessa, B., Higbed, L., & Nutt, D. (2019). A review of 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy. Front. Psychiatry, 10, 138. https://doi.org/10.3389/fpsyt.2019.00138.

    • Search Google Scholar
    • Export Citation
  • van Wel, J., Kuypers, K., Theunissen, E., Bosker, W., Bakker, K., & Ramaekers, J. (2012). Effects of acute MDMA intoxication on mood and impulsivity: Role of the 5-HT(2) and 5-HT(1) receptorsPlos One, 7, e40187. https://doi.org/10.1371/journal.pone.0040187.

    • Search Google Scholar
    • Export Citation
  • Vegting, Y., Reneman, L., & Booij, J. (2016). The effects of ecstasy on neurotransmitter systems: A review on the findings of molecular imaging studies. Psychopharmacology, 233(19–20), 34733501. https://doi.org/10.1007/s00213-016-4396-5.

    • Search Google Scholar
    • Export Citation
  • Vermetten, E., & Yehuda, R. (2020). MDMA-assisted psychotherapy for posttraumatic stress disorder: A promising novel approach to treatment. Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology, 45(1), 231232. https://doi.org/10.1038/s41386-019-0482-9.

    • Search Google Scholar
    • Export Citation
  • Videler, A. C., Hutsebaut, J., Schulkens, J. E. M., Sobczak, S., & van Alphen, S. P. J. (2019). A life span perspective on borderline personality disorder. Current Psychiatry Reports, 21(7), 51. https://doi.org/10.1007/s11920-019-1040-1.

    • Search Google Scholar
    • Export Citation
  • Yazar-Klosinski, B., & Mithoefer, M. (2017). Potential psychiatric uses for MDMA. Clinical Pharmacology and Therapeutics, 101(2), 194196. https://doi.org/10.1002/cpt.565.

    • Search Google Scholar
    • Export Citation
  • Zanarini, M., & Frankenburg, F. (2007). The essential nature of borderline psychopathology. Journal of Personality Disorders, 21(5), 518535. https://doi.org/10.1521/pedi.2007.21.5.518.

    • Search Google Scholar
    • Export Citation
  • Agrawal, H. R., Gunderson, J., Holmes, B. M., & Lyons-Ruth, K. (2004). Attachment studies with borderline patients: A review. Harvard Review of Psychiatry, 12(2), 94104.

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  • Alvarez-Tomás, I., Soler, J., Bados, A., Martín-Blanco, A., Elices, M., Carmona, C., et al. (2017). Long-term course of borderline personality disorder: A prospective 10-year follow-up study. Journal of Personality Disorders, 31, 590-605. https://doi.org/10.1521/pedi_2016_30_269. Epub 2016 Oct 17. PMID: 27749187.

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  • Amad, A., Ramoz, N., Peyre, H., Thomas, P., & Gorwood, P. (2019). FKBP5 gene variants and borderline personality disorder. Journal of Affective Disorders, 248, 2628. https://doi.org/10.1016/j.jad.2019.01.025.

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  • American Psychiatric Association Practice Guidelines (2001). Practice guideline for the treatment of patients with borderline personality disorder. The American Journal of Psychiatry, 158(10 Suppl), 152. https://doi.org/10.1176/appi.ajp.158.1.1.

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  • Bershad, A., Mayo, L., Van Hedger, K., McGlone, F., Walker, S., & de Wit, H. (2019). Effects of MDMA on attention to positive social cues and pleasantness of affective touch. Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology, 44(10), 16981705. https://doi.org/10.1038/s41386-019-0402-z.

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  • Bexis, S., & Docherty, J. (2005). Role of alpha2A-adrenoceptors in the effects of MDMA on body temperature in the mouse. British Journal of Pharmacology, 146, 16. https://doi.org/10.1038/sj.bjp.0706320.

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  • Biskin, R. (2015). The lifetime course of borderline personality disorder. Canadian Journal of Psychiatry. Revue canadienne de psychiatrie, 60(7), 303308. https://doi.org/10.1177/070674371506000702.

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  • Bornovalova, M. A., Hicks, B. M., Iacono, W. G., & McGue, M. (2009). Stability, change, and heritability of borderline personality disorder traits from adolescence to adulthood: A longitudinal twin study. Development and Psychopathology, 21(4), 13351353.

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  • Brodsky, B., & Stanley, B. (2002). Dialectical behavioral therapy for borderline personality disorder. Psychiatric Annals, 32(6), 337345. https://doi.org/10.3928/0048-5713-20020601-09.

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  • Carhart-Harris, R., Wall, M., Erritzoe, D., Kaelen, M., Ferguson, B., De Meer, I., et al. (2014). The effect of acutely administered MDMA on subjective and BOLD-fMRI responses to favourite and worst autobiographical memories. The International Journal of Neuropsychopharmacology, 17(4), 527540. https://doi.org/10.1017/S1461145713001405.

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  • Choi-Kain, L., Finch, E., Masland, S., Jenkins, J., & Unruh, B. (2017). What works in the treatment of borderline personality disorder. Current Behavioral Neuroscience Reports, 4(1), 2130. https://doi.org/10.1007/s40473-017-0103-z.

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  • Cristea, I., Gentili, C., Cotet, C., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry, 74, 319328. https://doi.org/10.1001/jamapsychiatry.2016.4287.

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  • dos Santos, R., Osorio, F., Crippa, J., & Hallak, J. (2016). Classical hallucinogens and neuroimaging: A systematic review of human studies: Hallucinogens and neuroimaging. Neuroscience and Biobehavioral Reviews, 71, 715-728. https://doi.org/10.1016/j.neubiorev.2016.10.026.

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  • Feduccia, A., & Duvauchelle, C. (2008). Auditory stimuli enhance MDMA-conditioned reward and MDMA-induced nucleus accumbens dopamine, serotonin and locomotor responses. Brain Research Bulletin, 77(4), 189196. https://doi.org/10.1016/j.brainresbull.2008.07.007.

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  • Feduccia, A., & Mithoefer, M. (2018). MDMA-assisted psychotherapy for PTSD: Are memory reconsolidation and fear extinction underlying mechanisms? Progress in Neuro-Psychopharmacology, 84, 221228. https://doi.org/10.1016/j.pnpbp.

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  • Ford, J., & Courtois, C. (2014). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Person. Disorder and Emotion Dysregulation, 1, 9. https://doi.org/10.1186/2051-6673-1-9.

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  • Freye, E. (2009). Pharmacological effects of MDMA in man. In Pharmacology and abuse of Cocaine, Amphetamines, Ecstasy and related designer drugs (pp. 151160). Dordrecht: Springer Netherlands. https://doi.org/10.1007/978-90-481-2448-0_24.

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  • Gabbard, G. (2014). Psychodynamic psychiatry in clinical practice. American Psychiatric Pub.

  • Goodman, M., & Yehuda, R. (2002). The relationship between psychological trauma and borderline personality disorder. Psychiatric Annals.

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    • Export Citation
  • Gunderson, J., Shea, M., Skodol, A., McGlashan, T., Morey, L., Stout, R., Zanarini, M., Grilo, C., Oldham, J., & Keller, M. (2000). The collaborative longitudinal personality disorders study: Development, aims, design, and sample characteristics. Journal of Personality Disorders, 14(4), 300315. https://doi.org/10.1521/pedi.2000.14.4.300.

    • Search Google Scholar
    • Export Citation
  • Gunderson, J. G., Stout, R. L., McGlashan, T. H., Shea, M. T., Morey, L. C., Grilo, C. M., et al. (2011). Ten-year course of borderline personality disorder: Psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Archives of General Psychiatry, 68(8), 827837.

    • Search Google Scholar
    • Export Citation
  • Jerome, L., Feduccia, A., Wang, J., Hamilton, S., Yazar-Klosinski, B., Emerson, A., et al. (2020). Long-term follow-up outcomes of MDMA-assisted psychotherapy for treatment of PTSD: A longitudinal pooled analysis of six phase 2 trials. Psychopharmacology, 37(8), 24852497. https://doi.org/10.1007/s00213-020-05548-2.

    • Search Google Scholar
    • Export Citation
  • Linehan, M. (2016). DBT skills training manual for treating borderline personality disorder (2nd ed.). New York: Guilford Press.

  • Linehan, M., Dimeff, L., Koerner, K., & Miga, E. (2014). Research on dialectical behavior therapy: Summary of the data to date. http://behavioraltech.org/downloads/research-on-dbt_summary-of-data-to-date.pdf.

    • Search Google Scholar
    • Export Citation
  • Mier, D., Lis, S., Esslinger, C., Sauer, C., Hagenhoff, M., Ulferts, J., et al. (2012). Neuronal correlates of social cognition in borderline personality disorder. Social Cognitive and Affective Neuroscience Electronic Resource, 8(5), 531537. https://doi.org/10.1093/scan/nss028.

    • Search Google Scholar
    • Export Citation
  • Mitchell, J. M., Bogenschutz, M., Lilienstein, A., Harrison, C., Kleiman, S., Parker-Guilbert, K., et al. (2021). MDMA-Assisted therapy for severe PTSD: A randomized, double-blind, placebo-controlled phase 3 study. Nature Medicine, 27, 10251033. https://doi.org/10.1038/s41591-021-01336-3.

    • Search Google Scholar
    • Export Citation
  • Mitchell, J. M., Ot’alora, G. M., van der Kolk, B., et al. (2023). MDMA-Assisted therapy for moderate to severe PTSD: A randomized, placebo-controlled phase 3 trial. Nature Medicine. https://doi.org/10.1038/s41591-023-02565-4.

    • Search Google Scholar
    • Export Citation
  • Mithoefer, M., Feduccia, A., Jerome, L., Mithoefer, A., Wagner, M., Walsh, Z., et al. (2019). MDMA-Assisted psychotherapy for treatment of PTSD: Study design and rationale for phase 3 trials based on pooled analysis of six phase 2 randomized controlled trials. Psychopharmacology, 236(9), 27352745. https://doi.org/10.1007/s00213-019-05249-5.

    • Search Google Scholar
    • Export Citation
  • Mithoefer, M., Wagner, M., Mithoefer, A., Jerome, L., & Doblin, R. (2011). The safety and efficacy of {+/−}3,4-methylenedioxymethamphetamine-assisted psychotherapy in subjects with chronic, treatment-resistant posttraumatic stress disorder: The first randomized controlled pilot study. Journal of Psychopharmacology (Oxford), 25(4), 439452. https://doi.org/10.1177/0269881110378371.

    • Search Google Scholar
    • Export Citation
  • Nardou, R., Lewis, E., Rothhaas, R., Xu, R., Yang, A., Boyden, E., et al. (2019). Oxytocin-dependent reopening of a social reward learning critical period with MDMA. Nature, 569, 116120. https://doi.org/10.1038/s41586-019-1075-9.

    • Search Google Scholar
    • Export Citation
  • Nichols, D. (2016). Psychedelics - Pharmacological Reviews, 68(2), 264355. https://doi.org/10.1124/pr.115.011478.

  • Nolte, T., Bolling, D. Z., Hudac, C. M., Fonagy, P., Mayes, L., & Pelphrey, K. A. (2013). Brain mechanisms underlying the impact of attachment-related stress on social cognition. Frontiers in Human Neuroscience, 7, 816.

    • Search Google Scholar
    • Export Citation
  • Nutt, D., King, L. A., & Nichols, D. E. (2013). Effects of schedule I drug laws on neuroscience research and treatment innovation. Nature Reviews Neuroscience.

    • Search Google Scholar
    • Export Citation
  • Palhano-Fontes, F., Barreto, D., Onias, H., Andrade, K., Novaes, M., Pessoa, J., et al. (2019). Rapid antidepressant effects of the psychedelic ayahuasca in treatment-resistant depression: A randomized placebo-controlled trial. Psychological Medicine, 49, 655663. https://doi.org/10.1017/S0033291718001356.

    • Search Google Scholar
    • Export Citation
  • Pascual, J., Silvia, O., Soler, J., Barrachina, J., Álvarez, E., & Victor, P. (2004). Ziprasidone in the acute treatment of borderline personality disorder in psychiatric emergency services. The Journal of Clinical Psychiatry, 65, 12811282. https://doi.org/10.4088/JCP.v65n0918b.

    • Search Google Scholar
    • Export Citation
  • Ripoll, L. H. (2013). Psychopharmacologic treatment of borderline personality disorder. Dialogues in Clinical Neuroscience, 15(2), 213224. https://doi.org/10.31887/DCNS.2013.15.2/lripoll.

    • Search Google Scholar
    • Export Citation
  • Roepke, S., Vater, A., Preißler, S., Heekeren, H. R., & Dziobek, I. (2013). Social cognition in borderline personality disorder. The Florida Nurse, 6, 195.

    • Search Google Scholar
    • Export Citation
  • Scott, L. N., Levy, K. N., & Pincus, A. L. (2009). Adult attachment, personality traits, and borderline personality disorder features in young adults. Journal of Personality Disorders, 23(3), 258280.

    • Search Google Scholar
    • Export Citation
  • Sessa, B., Higbed, L., & Nutt, D. (2019). A review of 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy. Front. Psychiatry, 10, 138. https://doi.org/10.3389/fpsyt.2019.00138.

    • Search Google Scholar
    • Export Citation
  • van Wel, J., Kuypers, K., Theunissen, E., Bosker, W., Bakker, K., & Ramaekers, J. (2012). Effects of acute MDMA intoxication on mood and impulsivity: Role of the 5-HT(2) and 5-HT(1) receptorsPlos One, 7, e40187. https://doi.org/10.1371/journal.pone.0040187.

    • Search Google Scholar
    • Export Citation
  • Vegting, Y., Reneman, L., & Booij, J. (2016). The effects of ecstasy on neurotransmitter systems: A review on the findings of molecular imaging studies. Psychopharmacology, 233(19–20), 34733501. https://doi.org/10.1007/s00213-016-4396-5.

    • Search Google Scholar
    • Export Citation
  • Vermetten, E., & Yehuda, R. (2020). MDMA-assisted psychotherapy for posttraumatic stress disorder: A promising novel approach to treatment. Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology, 45(1), 231232. https://doi.org/10.1038/s41386-019-0482-9.

    • Search Google Scholar
    • Export Citation
  • Videler, A. C., Hutsebaut, J., Schulkens, J. E. M., Sobczak, S., & van Alphen, S. P. J. (2019). A life span perspective on borderline personality disorder. Current Psychiatry Reports, 21(7), 51. https://doi.org/10.1007/s11920-019-1040-1.

    • Search Google Scholar
    • Export Citation
  • Yazar-Klosinski, B., & Mithoefer, M. (2017). Potential psychiatric uses for MDMA. Clinical Pharmacology and Therapeutics, 101(2), 194196. https://doi.org/10.1002/cpt.565.

    • Search Google Scholar
    • Export Citation
  • Zanarini, M., & Frankenburg, F. (2007). The essential nature of borderline psychopathology. Journal of Personality Disorders, 21(5), 518535. https://doi.org/10.1521/pedi.2007.21.5.518.

    • Search Google Scholar
    • Export Citation
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Editor-in-Chief:

Attila Szabo - University of Oslo

E-mail address: attilasci@gmail.com

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Zsófia Földvári, Oslo University Hospital

 

Associate Editors:

  • Alan K. Davis - The Ohio State University & Johns Hopkins University, USA
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  • David Luke - University of Greenwich, London, UK
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  • Jeremy Narby - Swiss NGO Nouvelle Planète, Lausanne, Switzerland
  • Stephen Szára - Retired from National Institute on Drug Abuse, Bethesda, USA
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Book Reviews Editor:

Michael Winkelman - Retired from Arizona State University, Tempe, USA

Editorial Board

  • Gábor Andrássy - University of Debrecen, Debrecen, Hungary
  • Paulo Barbosa - State University of Santa Cruz, Bahia, Brazil
  • Michael Bogenschutz - New York University School of Medicine, New York, NY, USA
  • Petra Bokor - University of Pécs, Pécs, Hungary
  • Jose Bouso - Autonomous University of Madrid, Madrid, Spain
  • Zoltán Brys - Multidisciplinary Soc. for the Research of Psychedelics, Budapest, Hungary
  • Susana Bustos - California Institute of Integral Studies San Francisco, USA
  • Robin Carhart-Harris - Imperial College, London, UK
  • Per Carlbring - Stockholm University, Sweden
  • Valerie Curran - University College London, London, UK
  • Alicia Danforth - Harbor-UCLA Medical Center, Los Angeles, USA
  • Rick Doblin - Boston, USA
  • Rafael G. dos Santos - University of Sao Paulo, Sao Paulo, Brazil
  • Genis Ona Esteve - Rovira i Virgili University, Spain
  • Silvia Fernandez-Campos
  • Zsófia Földvári - Oslo University Hospital, Oslo, Norway
  • Andrew Gallimore - University of Cambridge, Cambridge, UK
  • Neal Goldsmith - private practice, New York, NY, USA
  • Charles Grob - Harbor-UCLA Medical Center, Los Angeles, CA, USA
  • Stanislav Grof - California Institute of Integral Studies, San Francisco, CA, USA
  • Karen Grue - private practice, Copenhagen, Denmark
  • Jiri Horacek - Charles University, Prague, Czech Republic
  • Lajos Horváth - University of Debrecen, Debrecen, Hungary
  • Robert Jesse - Johns Hopkins University School of Medicine, Baltimore, MD, USA
  • Matthew Johnson - Johns Hopkins University School of Medicine, Baltimore, MD, USA
  • Eli Kolp - Kolp Institute New, Port Richey, FL, USA
  • Stanley Krippner - Saybrook University, Oakland, CA, USA
  • Evgeny Krupitsky - St. Petersburg State Pavlov Medical University, St. Petersburg, Russia
  • Rafael Lancelotta - Innate Path, Lakewood, CO, USA
  • Anja Loizaga-Velder - National Autonomous University of Mexico, Mexico City, Mexico
  • Luis Luna - Wasiwaska Research Center, Florianópolis, Brazil
  • Katherine MacClean - Johns Hopkins University School of Medicine, Baltimore, MD, USA
  • Deborah Mash - University of Miami School of Medicine, Miami, USA
  • Friedericke Meckel - private practice, Zurich, Switzerland
  • Ralph Metzner - California Institute of Integral Studies, San Francisco, CA, USA
  • Michael Mithoefer - private practice, Charleston, SC, USA
  • Levente Móró - University of Turku, Turku, Finland
  • David Nichols - Purdue University, West Lafayette, IN, USA
  • David Nutt - Imperial College, London, UK
  • Torsten Passie - Hannover Medical School, Hannover, Germany
  • Janis Phelps - California Institute of Integral Studies, San Francisco, CA, USA
  • József Rácz - Semmelweis University, Budapest, Hungary
  • Christian Rätsch - University of California, Los Angeles, Los Angeles, CA, USA
  • Sidarta Ribeiro - Federal University of Rio Grande do Norte, Natal, Brazil
  • William Richards - Johns Hopkins School of Medicine, Baltimore, MD, USA
  • Stephen Ross - New York University, New York, NY, USA
  • Brian Rush - University of Toronto, Toronto, Canada
  • Eduardo Schenberg - Federal University of São Paulo, São Paulo, Brazil
  • Ben Sessa - Cardiff University School of Medicine, Cardiff, UK
  • Lowan H. Stewart - Santa Fe Ketamine Clinic, NM, USA (Medical Director)
  • Rebecca Stone - Emory University, Atlanta, GA, USA
  • Rick Strassman - University of New Mexico School of Medicine, Albuquerque, NM, USA
  • Csaba Szummer - Károli Gáspár University of the Reformed Church, Budapest, Hungary
  • Manuel Torres - Florida International University, Miami, FL, USA
  • Luís Fernando Tófoli - University of Campinas, Campinas, Brazil State
  • Malin Uthaug - Maastricht University, Maastricht, The Netherlands
  • Julian Vayne - Norwich, UK
  • Nikki Wyrd - Norwich, UK

Attila Szabo
University of Oslo

E-mail address: attilasci@gmail.com

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Impact Factor
without
Journal Self Cites
4.1
5 Year
Impact Factor
n/a
Journal Citation Indicator 0.97
Rank by Journal Citation Indicator

Pharmacology & Pharmacy 91/362
Psychiatry 69/264

Scimago  
Scimago
H-index
5
Scimago
Journal Rank
0.416
Scimago Quartile Score

Anthropology Q1
Biological Psychiatry Q4
Clinical Psychology Q3
Health (social science) Q3
Pharmacology Q3
Psychiatry and Mental Health Q3
Social Psychology Q3

Scopus  
Scopus
Cite Score
4.2
Scopus
CIte Score Rank
Anthropology 31/468 (93rd PCTL)
Health (social science) 78/344 (77th PCTL)
Social Psychology 96/292 (70th PCTL)
Clinical Psychology 96/292 (67th PCTL)
Psychiatry and Mental Health 219/531 (58th PCTL)
Pharmacology (medical) 115/260 (55th PCTL)
Biological Psychiatry 30/47 (37th PCTL)
Scopus
SNIP
0.627

2021  
Web of Science  
Total Cites
WoS
not indexed
Journal Impact Factor not indexed
Rank by Impact Factor

not indexed

Impact Factor
without
Journal Self Cites
not indexed
5 Year
Impact Factor
not indexed
Journal Citation Indicator not indexed
Rank by Journal Citation Indicator

not indexed

Scimago  
Scimago
H-index
2
Scimago
Journal Rank
not yet available
Scimago Quartile Score Anthropology (Q3)
Biological Psychiatry (Q4)
Clinical Psychology (Q4)
Health (social science) (Q4)
Pharmacology (medical) (Q4)
Psychiatry and Mental Health (Q4)
Social Psychology (Q4)
Scopus  
Scopus
Cite Score
0,9
Scopus
CIte Score Rank
Anthropology 186/443 (Q2)
Health (social science) 234/323 (Q3)
Clinical Psychology 213/292 (Q3)
Pharmacology (medical) 190/255 (Q3)
Psychiatry and Mental Health 419/529 (Q4)
Social Psychology 243/296 (Q4)
Biological Psychiatry 38/43 (Q4)
Scopus
SNIP
0,381

2020  
CrossRef Documents 8
WoS Cites 37
WoS H-index 4
Days from submission to acceptance 95
Days from acceptance to publication 75
Acceptance Rate 41%

2019  
WoS
Cites
11
CrossRef
Documents
35
Acceptance
Rate
77%

 

Journal of Psychedelic Studies
Publication Model Gold Open Access
Submission Fee none
Article Processing Charge €990
Subscription Information Gold Open Access
Regional discounts on country of the funding agency World Bank Lower-middle-income economies: 50%
World Bank Low-income economies: 100%
Further Discounts Corresponding authors, affiliated to an EISZ member institution subscribing to the journal package of Akadémiai Kiadó: 100%. 
   

Journal of Psychedelic Studies
Language English
Size A4
Year of
Foundation
2016
Volumes
per Year
1
Issues
per Year
3
Founder Akadémiai Kiadó
Debreceni Egyetem
Eötvös Loránd Tudományegyetem
Károli Gáspár Református Egyetem
Founder's
Address
H-1117 Budapest, Hungary 1516 Budapest, PO Box 245.
H-4032 Debrecen, Hungary Egyetem tér 1.
H-1053 Budapest, Hungary Egyetem tér 1-3.
H-1091 Budapest, Hungary Kálvin tér 9.
Publisher Akadémiai Kiadó
Publisher's
Address
H-1117 Budapest, Hungary 1516 Budapest, PO Box 245.
Responsible
Publisher
Chief Executive Officer, Akadémiai Kiadó
ISSN 2559-9283 (Online)

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