James, who prefers not to use his last name for reasons that will shortly become obvious, is a 21-year-old student majoring in electrical engineering. He’s been interested in 3,4-methylenedioxymethamphetamine, better known as MDMA, since he was a teenager, when he felt his social inhibitions might be resolved by taking the illegal drug. Also known as ecstasy, the chemical provides what the name implies: a significant reduction in anxiety and a boost in emotional interaction.
“I was not very outgoing,” he says. “I decided to change that as soon as I could.”
After finding what he considered a reliable source, James took one pill. Forty-five minutes later, he became talkative and gregarious. He started using it every weekend.
One month later, he awoke to a woman with a mutilated face and a skeletal body hovering over him. She placed a hand over his face. He told his body to struggle. It didn’t.
“The whole experience lasted two minutes or less,” he says, “but it felt like a lifetime.”
James is one of a growing number of recreational MDMA users who have reported incidences of sleep paralysis and other nocturnal disturbances. The same mechanism that produces its euphoric effects — agitating and changing the brain’s production of and relationship with serotonin —may also be the reason it’s quickly becoming the literal stuff nightmares are made of.
The Making of MDMA
Drug giant Merck was the first to patent the MDMA compound in 1914 on the belief it could be used as an intermediary — or partial formulation — to synthesize other drugs. After being relegated to pharmaceutical purgatory for the next half-century, a chemist named Alex Shulgin used the company’s formula to resurrect it. Having taken note of its hallucinogenic and emotionally potent effects, Shulgin told a therapist friend, Leo Zeff, about a chemical that might be able to facilitate self-discovery. By releasing the feel-good neurotransmitter serotonin and having secondary effects on dopamine, oxytocin, and norepinephrine, MDMA could induce the ultimate case of the warm-and-fuzzies.
In the 1970s, Zeff began using MDMA in psychotherapy sessions and trained other mental health professionals to use it for medicinal purposes. The results seemed promising, but off-label use by the night club culture of the 1980s drew the attention of the Drug Enforcement Agency (DEA), who labeled it a Schedule I substance — illegal to buy, sell, or possess, even with a prescription. Using MDMA for legitimate therapy was abandoned.
Partygoers paid little attention. Absent any supervision, they continued to use ecstasy for their own self-healing. Engorged with euphoria and stimulated by the drug’s amphetamine-like high, “E” became a drug trendy enough to compete with cocaine. Pills were often manufactured using popular brand logos or shapes.
While black market pills emblazoned with Mickey Mouse promised a fun, happy time, the sweaty palms, hyperthermia, teeth grinding and kidney failure experienced by some users were a reminder that MDMA is neurotoxic. Use enough of it — and “enough” depends entirely on the individual — and your brain can experience permanent changes. “Some people can develop hyperthermia after one dose while their friends are fine,” says Una McCann, M.D., Professor of Psychiatry at Johns Hopkins University School of Medicine. “We don’t know why that happens.”
What McCann and other researchers do know is that MDMA’s manipulation of serotonin can have severe consequences. “Once you produce neurotoxic injuries, including serotonin changes, the brain doesn’t have the capacity to grow new neurons,” she says. “While it can compensate, the brain does not recover from an insult like that.”
Rolling into Bed
Though MDMA has never been directly implicated in bouts of sleep paralysis in clinical studies, serotonin is a crucial component of sleep structure. “Serotonin is responsible for mediating arousal,” says William Winter, M.D., a neurologist specializing in sleep disorders. “If serotonin is blocked or deficient, it would impair the sleeper’s ability to fully arouse.” MDMA shortens the filaments on the ends of serotonin receptors, making it difficult for them to communicate with other cells. Combined with the paralysis most everyone experiences during sleep to avoid physical reactions to dreams, it’s not difficult to understand why MDMA can cause users to get caught in a glue trap of abnormal arousals.
Paul — not his real name — used MDMA every other weekend from the ages of 16 to 20. Now 27 and a podcast host, he recalls that his excessive use eventually led to a sustained bout of sleep paralysis that lasted for two tortuous weeks. “It felt like dread, like something horrible was coming,” he says. He could only move his eyes, scanning his bedroom for the female apparition — in “grey scale,” he remembers — that would sometimes try to smother him.
By his own admission, Paul took doses that he suspected were of 80 percent purity. A compound risk of MDMA is that, even with the kinds of diagnostic test kits available to users, there is no guarantee a pill might not contain unidentified substances that dilute the primary ingredient. Coupled with the proven toxicity of the drug itself, the practice of “rolling,” or binging for a weekend, can impact sleep quality long after the party is over.
The Sleep-MDMA Connection
Rather than concentrate on sleep patterns, McCann was curious to see what MDMA might do to the brain as a whole. But her research subjects who reported taking at least 25 doses of the drug displayed an unexpected result: their sleep was a mess.
Thin, young participants who otherwise had no predisposition to sleep apnea were recorded having substantial interruptions in breathing during sleep; they also displayed a decrease in Stage II, the most abundant and restorative phase. Owing to serotonin changes, stimulant effects, or unknown mechanisms, McCann discovered that MDMA users had poor sleep quality for weeks or months afterward.
In examining people who took MDMA and were sleep-deprived and comparing them with MDMA-free somnolent subjects, the MDMA group also had marked reductions in cognitive functioning — in short, they had less of a “buffer” before succumbing to the effects of sleep deprivation. “Their cognitive reserve was much lower,” McCann says. “They rapidly developed reductions in their ability to perform simple tasks.”
Though no one can declare any dose as safe, MDMA users who experience repeated episodes of sleep paralysis seem to have been over-indulging. “Steve,” a 24-year-old economist, recalls spending a year ingesting the drug virtually every weekend — sometimes up to 10 pills over a three-day period. “It was way too much,” he says. “It was stupid. I acknowledge this.”
The pills were called Riddlers, reliably sourced from Holland and expected to contain roughly 200mg of MDMA. After several pills, Steve “felt a presence” of someone leaning over his bed, trapped in a nightmare he couldn’t exit. As with James and Paul, the paralysis and the other psychological effects prompted a drastic reduction in use. “The cost to benefit wasn’t worth it anymore,” Steve says. “You get used to MDMA, and it’s not worth the crushing comedown.”
The Upside of Ecstasy
As a recreational drug, MDMA makes a fairly poor bed partner. But there’s increasing evidence that Shulgin’s original intent might turn out to be prophetic. A number of clinics are conducting trials of MDMA to treat sufferers of post-traumatic stress disorder (PTSD) after conventional therapy has failed.
Michael Mithoefer, M.D., a principal investigator for the non-profit research group Multidisciplinary Association for Psychedelic Studies (MAPS), just completed a study involving veterans from the military, law enforcement and firefighting. It follows a number of studies indicating MDMA could finally free tormented minds from the residue of traumatic experiences.
“In a typical session, someone might take 75 to 100mg of MDMA,” Mithoefer says. “And then we let the process unfold.” Patients can sit for eight hours, talking over their fears and memories with a therapist while the MDMA provides an emotional cushion. “The process provides perspective,” he says. “It can be an effective catalyst for reprocessing trauma.”
MDMA has been used in low doses in more than 1100 patients with no significant adverse effects. The largest study, reported in 2010, found that 83 percent of PTSD sufferers treated with the drug experienced a significant reduction in symptoms. The research is expanding to include anxiety alleviation in autism, in couple’s therapy and in people with life-threatening illnesses. More remarkable, Mithoefer says, is a recently-completed study that shows patients with reduced PTSD symptoms as a result of MDMA have had one ironic side effect: improved sleep quality.
“We measured sleep quality both before and after [the trial],” he says. “When it’s in the system, it tends to interfere with sleep. But taking it three to six times, one month apart, is different. We’ve seen promising improvements in sleep quality.”
Mithoefer and his peers are discovering—in a highly controlled environment—what some MDMA users had to find out the hard way. Since dropping his use down to just four times a year, James has not had a reoccurrence of his sleep paralysis or nightmares. “They were kind of a wake-up call for me, and I’m glad they happened,” he says. “It’s not a drug you want to abuse. It has great therapeutic benefits, but it demands respect.”