Phase II Clinical Trial Testing the Safety and Efficacy of 3,4-Methylenedioxymethamphetamine (MDMA)-Assisted Psychotherapy in Subjects With Chronic Posttraumatic Stress Disorder
Phase: PHASE2
Conditions: Posttraumatic Stress Disorder
Sponsor: Lykos Therapeutics

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  0 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
Study Protocol 
Phase II clinical trial testing the safety and efficacy of 3,4-
methylenedioxymethamphetamine (MDMA)-assisted psychotherapy in subjects  
with chronic posttraumatic stress disorder. 
Study # 63-384 
Original Protocol: September 24, 2003 
Protocol Amendment #1: November 17, 2004 
Protocol Amendment #2:  June 23, 2005 
Protocol Amendment# 3 March 13, 2006 
Protocol Amendment # 4 November 10, 2006 
Protocol Amendment # 5 August 27, 2007 
 
 
 
Principal Investigator 
Michael C. Mithoefer MD 
208 Scott St. 
Mt. Pleasant, SC  29464 
 
Sponsor 
Multidisciplinary Association for 
Psychedelic Studies (MAPS) 
10424 Love Creek Rd., Ben Lomond CA 
95005-9467). 
 
 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  1 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
 
Investigators and Institutional Review Board................................................................ 2 
Aims and Goals ................................................................................................................. 3 
Specific Hypotheses........................................................................................................... 3 
Background ....................................................................................................................... 4 
Methods.............................................................................................................................. 7 
General Study Design ..................................................................................................... 7 
Data Analysis.................................................................................................................. 9 
Subjects......................................................................................................................... 11 
Who and Why ........................................................................................................... 11 
Total Number/Number per group ............................................................................. 11 
Inclusion/Exclusion Criteria ..................................................................................... 12 
Initial Contact Method and Informed Consent Process ................................................ 14 
Screening Process ......................................................................................................... 15 
Study Procedures ............................................................................................................ 15 
Study Outcome Measures ............................................................................................. 16 
Baseline Assessment........................................................................................................ 17 
Non-Experimental Psychotherapy Sessions ................................................................. 17 
Sessions Employing the Experimental Intervention.................................................... 18 
Drugs and Dosing ......................................................................................................... 18 
Measures during Experimental Intervention Session ................................................... 20 
Psychotherapeutic Procedures during Experimental Session ....................................... 20 
Monitoring for Toxicity................................................................................................ 22 
Research Follow Up........................................................................................................ 24 
Therapy Follow-up.......................................................................................................... 25 
Third Open-Label Experimental Session ..................................................................... 25 
Open Label Continuation for Placebo Subjects........................................................... 26 
Long-Term Follow-up .................................................................................................... 27 
Costs to Participants....................................................................................................... 28 
Treatment and Compensation of Study Related Injury.............................................. 28 
Risks to Participants....................................................................................................... 29 
Risks and Discomforts Associated with Drawing Blood.............................................. 29 
Risks and Discomforts Associated with Screening Procedure ..................................... 29 
Risks and Discomforts Associated with the Experimental Intervention ...................... 29 
Potential Neurotoxicity Associated with Ecstasy Use.................................................. 32 
Alternative treatments and procedures:....................................................................... 34 
Risk-Benefits Analysis .................................................................................................... 36 
References........................................................................................................................ 37 
Appendix A: Procedures for Treating Serious Adverse Events................................. 44 
Appendix B: Procedures used for Audio and Video Recording................................. 49 
  
 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  2 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
Investigators and Institutional Review Board 
 
Principal Investigator 
 
Michael C. Mithoefer MD 
208 Scott St., 
Mt. Pleasant, SC 29464 
 
Other Investigators 
 
Ann T. Mithoefer BSN 
208 Scott St., 
Mt. Pleasant, SC 29464 
 
Mark T. Wagner, Ph.D. 
Director, Neuropsychology Section 
Associate Professor of Neurology 
Medical University of South Carolina 
96 Johathan Lucas Street 
Charleston, SC 29425-9691. 
 
Melinda Edwards MD, 
208 Scott St. 
Mt. Pleasant SC 29464 
 
Michal Baird, MD 
308 Sta. 191/2 
Sullivan's Island, SC 29482 
 
Institutional Review Board 
 
Coperrnicus Group IRB 
118 MacKenan Dr., Suite 400 
Cary NC 27511 
 
 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  3 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
Aims and Goals 
 
The current protocol is a randomized double-blind placebo-controlled pilot study of the 
safety and effects of MDMA-assisted psychotherapy on symptoms of chronic, treatment-
resistant posttraumatic stress disorder (PTSD). This study follows three FDA-approved 
Phase I safety studies (one sponsored by MAPS and two by the National Institute on 
Drug Abuse), is endorsed by the principal investigators of all three of these studies, and is 
the first FDA-approved scientific study of MDMA-assisted psychotherapy in any patient 
population. 
  
Findings from this study will be used to guide development of a second pilot study to 
refine and standardize MDMA-assisted psychotherapy for PTSD patients.  If results of 
both of these pilot studies, plus another small pilot study to be conducted in Israel, are 
promising, the data gathered will be used to inform the design of two large (N= at least 
280) multi-site Phase III studies of MDMA-assisted psychotherapy as a treatment for 
PTSD.  MAPS' Clinical Plan (Doblin 2002) will require at least 5 years and will involve 
at least 600 subjects. 
 
Specific Hypotheses 
 
The proposed study is intended to test whether MDMA-assisted psychotherapy can be 
safely administered to people with treatment-resistant PTSD or veterans with PTSD 
symptoms that have endured for one to five years who are unable or unwilling to undergo 
conventional psychotherapy or pharmacotherapy for PTSD, and if it will produce 
improvement in PTSD signs and symptoms four days after each of two experimental 
intervention sessions and again at a follow-up evaluation conducted two months after the 
second experimental session.  Improvement will be indicated by lower scores on 
established outcome measures of PTSD symptoms that were used in prior studies which 
formed the basis of FDA decisions to approve Zoloft and Paxil for the treatment of 
PTSD, with participants in the MDMA condition expected to have lower scores than 
participants in the placebo condition.  It is also expected that MDMA will not affect 
cognitive function when measured two months after the second experimental session.  
The hypotheses to be tested by the proposed study are stated below:  
 
1. Volunteers receiving MDMA-assisted psychotherapy will experience (trends toward) 
a greater decrease in signs and symptoms of PTSD than controls after each 
experimental session, as measured by the clinician-rated PTSD Scale (CAPS), the 
self-reported Impact of Events Scale (IES) and Symptoms Checklist-90-R (SCL-90-
R). 
 
2. Volunteers receiving MDMA-assisted psychotherapy will experience (trends toward) 
a greater decrease in signs and symptoms of PTSD than controls at two months 
after the second drug-assisted (MDMA or placebo) session. 
 
3. Exposure to MDMA will not be associated with neurocognitive toxicity as assessed 
by the Repeatable Battery for Assessment of Neuropsychological Status (RBANS), 
the Paced Auditory Serial Addition Task (PASAT) and the Rey-Osterrieth Complex 
Figure Test. 
 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  4 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
The primary outcome measure evaluating efficacy will be the Clinician-Administered 
PTSD Scale (CAPS). Secondary outcome measures evaluating efficacy will be the 
Impact of Event Scale (IES) and the Symptom Checklist 90-R.  
 
The assessment of neuropsychological status serves as a means of safety evaluation and 
is measured by the Repeatable Battery for the Assessment of Neuropsychological Status 
(RBANS), the Paced Auditory Serial Addition Task (PASAT), and the Rey-Osterrieth 
Complex Figure. The NEO Personality Inventory is a neuropsychological measure of 
personality that is also part of our safety evaluation. 
 
Background 
 
MDMA is a ring-substituted phenylisopropylamine derivative with a unique profile of 
psychopharmacological effects that make it well suited to intensive psychotherapy.  
MDMA has been hypothesized to represent a new class of psychoactive agents, called 
entactogens (Nichols 1986; Nichols 1990), producing feelings of closeness to others, 
empathy, well being, and insightfulness, with little perceived loss of control (Grinspoon 
and Bakalar 1986; Hegadoren et al. 1999; Nichols 1986; Shulgin and Nichols 1978).  
There is considerable previous human experience with the use of MDMA in the context 
of psychotherapy. Before MDMA was classified in 1985 as a controlled substance, a 
number of therapists employed it as an adjunct to psychotherapy in the United States and 
Europe (Adamson 1985; Gasser 1994; Greer and Tolbert 1998; 1986; Grinspoon and 
Bakalar 1986).  Although no properly controlled trials were conducted, these therapists 
concluded that MDMA could be safely administered and was clinically useful in treating 
various sub-clinical or clinical psychiatric conditions, including posttraumatic stress 
disorder.  More recently, placebo-controlled clinical trials have confirmed reports from 
therapists that MDMA produces an easily-controlled intoxication characterized by 
euphoria, increased well being, sociability, self-confidence, and extroversion (Cami et al. 
2000; Harris et al. 2002; Liechti et al. 2001a; Tancer et al. 2001; Vollenweider et al. 
1998).   
 
Posttraumatic stress disorder (PTSD) occurs in response to a traumatic event or events.  It 
is most likely to occur following an event involving perceived personal threat, such as 
rape or physical assault (Breslau 1998).  Approximately 10% - 20% of people who 
experience a major trauma go on to develop PTSD, giving it an estimated 8% prevalence 
in the general population (Kessler et al. 1995).  In the National Comorbidity Study, the 
median time to remission was 36 months with treatment and 64 months without 
treatment.  In either subgroup, more than one-third still had symptoms several times per 
week 10 years later (Kessler et al. 1995).  People with PTSD frequently develop other 
comorbidities, particularly affective and substance abuse disorders (Kessler et al. 1995).  
In addition to the psychiatric manifestations, individuals with PTSD have an increased 
incidence of physical problems and impairments in social and occupational functioning 
that lead to increased healthcare utilization and decreased quality of life (Brady et al. 
2000: Kessler et al. 1999; Solomon and Davidson, 1997).  PTSD is clearly a public health 
problem that causes a great deal of suffering and accounts for a significant portion of 
health care costs.  It is also a disorder for which there are, to date, two FDA-approved 
medications [both selective serotonin reuptake inhibitors (SSRIs)] about which there are 
still many unanswered questions regarding psychological and pharmacological effects 
(Montgomery and Bech 2000).  The search for more effective treatments and a wider 
array of treatments is of substantial public health importance.   

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  5 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
 
Treatment goals for posttraumatic stress disorder include alleviating symptoms and 
interrupting the stress-induced neurochemical abnormalities produced by the condition.  
Developing drugs and psychotherapeutic treatments that will indirectly interrupt the 
destructive neurobiological changes by decreasing or eliminating the stress reactions to 
triggers and the chronic hyperarousal of PTSD may be one means of treating PTSD.  
Anecdotal reports of past experience with MDMA-assisted psychotherapy suggest that it 
could serve as such a treatment. On the basis of past reports of successful treatment of 
PTSD with MDMA-assisted therapy and on the basis of its reported entactogenic effects, 
we expect that psychotherapy conducted in combination with MDMA should produce 
symptomatic improvement in this population.   
 
Anecdotal accounts of the use of MDMA in people with PTSD-like symptoms (no formal 
diagnoses or evaluations were conducted) can be found on the MAPS website at the 
bottom of the MDMA page (http://www.maps.org/research/mdma/index.html#healing), 
in the Accounts of Healing section, and include an account of a woman treated for PTSD 
after rape and sexual abuse (http://www.maps.org/research/mdma/moaccount.html). 
Other anecdotal reports not dealing specifically with therapy in people with PTSD have 
also included accounts of people treated for PTSD-like symptoms (Metzner and  
Adamson 2001).   
 
Further reports of the therapeutic use of MDMA can be found in the testimony from the 
1985-1986 DEA Administrative Law Judge hearings on the scheduling of MDMA. 
Testimony was submitted by Dr. Greer (who had administered MDMA to about 80 
individuals and reported apparent benefits to the therapeutic alliance and to outcomes), 
Dr. Downing (who reported use of MDMA with 8 patients, 5 of whom he considered to 
have shown accelerated therapeutic progress), and Dr. Ingrasci (who reported 
successfully conducting approximately 150 MDMA sessions with about 100 patients), 
and others. Transcripts and documents from of these hearings can be found on the MAPS 
website at: http://www.maps.org/dea-mdma/ (in Section 6). No formal FDA-approved 
study of the therapeutic use of MDMA in any patient population has yet to be conducted, 
despite considerable efforts to obtain permission for such studies. 
 
Samuel Widmer, MD, Peter Gasser, MD, and other members of the Swiss Medical 
Society for Psycholytic Therapy received permission from the Swiss Ministry of Health 
to administer MDMA to patients from 1988 to 1993. During this time, 171 patients 
received MDMA with no significant adverse effects reported. In a follow-up survey, 
85.1% of 121 responding patients reported good or slight improvement during therapy, 
which included 6.8 ± 4.3 (1 - 16) MDMA sessions administered in the context of on-
going therapy. Unfortunately, no formalized research was conducted with these patients. 
Dr. Gasser’s report on the follow-up survey was published in the MAPS Bulletin and can 
be found at: http://www.maps.org/news-letters/v05n3/05303psy.html. 
 
The subject population of chronic PTSD patients was selected in part because these 
individuals have failed to obtain relief from currently available treatments and because of 
patient and therapist reports of benefits of MDMA-assisted psychotherapy in treating 
PTSD, from treatments conducted prior to the criminalization of MDMA in 1985.  The 
qualities that have been associated with MDMA in anecdotal reports (i.e. decreased 
defensiveness and enhanced therapeutic alliance) seem to have the potential to be 
particularly useful in the treatment of this disorder.  PTSD is a condition that involves 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  6 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
prominent fear responses. Revisiting traumatic experiences in psychotherapy is 
recognized to be of therapeutic value. Early clinical experience with MDMA is consistent 
with the hypothesis that it can increase therapeutic effectiveness in this population.  The 
combination of anxiolysis (reduction in fear and anxiety), euphoria, feelings of 
interpersonal closeness and facilitated recall for past events would seem to have the 
potential to maximize or amplify the benefits of psychotherapeutic interventions.  
 
MDMA primarily acts as a monoamine releaser, as well as possessing some direct effects 
on various neurotransmitter receptor sites (for further details, see Chapter 1 in the 
Investigator’s Brochure and Liechti and Vollenweider, 2001).  The relationships between 
the neurochemical and physiological effects of MDMA are poorly understood, but studies 
of subjective effects in humans indicate that potentially therapeutic actions may be at 
least partly due to monoamine releasing properties and to moderate activity at the 
serotonin 5HT2A receptor.  An imaging study also noted lower activity in the left 
amygdala after MDMA (Gamma et al. 2000), suggesting that MDMA inhibits or alters 
activity in areas of the brain that process fear-related stimuli. 
 
To date, several Phase I trials have been conducted in the United States, Spain and 
Switzerland.  MDMA has been administered to over 100 participants in controlled studies 
conducted within the United States, and to over 100 more individuals in controlled 
studies conducted in Europe.  When MDMA is used in therapeutic doses in a controlled 
setting, the risk/benefit ratio is favorable (Cami et al. 2000; de la Torre et al. 2000a; de la 
Torre et al. 2000b; Grob et al, In Preparation, Data presented to FDA; Grob et al. 1996; 
Harris et al. 2002; Lester et al. 2000a; b; Liechti and Vollenweider 2000a; b; Liechti et al, 
2001a: b; Mas et al. 1999; Pacifici et al. 2001; 2000; Tancer et al. 2001; Vollenweider et 
al. 1998; 1999).  MDMA appears to have risks that are similar to those of other 
structurally-related sympathomimetic compounds, such as methamphetamine, that have 
been used clinically for many years. 
 
Since the late 1970s, MDMA has been used by a growing number of individuals in non-
medical settings.  Illicit use of ecstasy (material sold as MDMA) is most commonly 
reported at dance events such as “rave” parties and at nightclubs but is not confined to 
these situations or subcultures.  In the United States, prevalence of ecstasy use reported in 
2000 was estimated to be 11.6% for young adults (ages 19-28).  While a number of 
serious adverse events, including fatalities, have been reported after illicit use of ecstasy 
in uncontrolled conditions, these are events are relatively rare when considering the 
prevalence of ecstasy use (Gore 1999; Baggott, 2002).   
 
There has been no evidence of significant acute or lasting toxicity in Phase I studies.  
This is noteworthy because animal studies have indicated a possibility of long-term 
serotonergic brain changes after high dose MDMA regimens (e.g., Hatzidimitriou et al. 
1999; Lew et al. 1996; Sabol et al. 1996) and some studies suggest clinically subtle 
neurocognitive changes may occur in a subset of repeated users of illicit MDMA and 
other drugs (e.g., Croft et al. 2000; Gouzoulis-Mayfrank et al. 2000).  In contrast, all 
available Phase I data indicate that it is unlikely that the MDMA exposures proposed in 
this protocol cause persisting measurable reduction in serotonin function or lasting 
neurocognitive deficits.  Tests of neurocognitive function have found that performance is 
not affected by participation in clinical MDMA trials (Boone et al. In Preparation, see 
also Table 2.5 in Investigator’s Brochure; Vollenweider et al. 2001; 2000).  
Vollenweider and colleagues (2000) presented positron emission tomography (PET) data 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  7 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
at the 2000 conference of the German Society for Psychiatry, Psychotherapy and 
Neuromedicine that found no change in estimated serotonin transporter binding sites four 
weeks after a dose of MDMA similar to our proposed dose of 125 mg was given to 
MDMA-naïve volunteers.    
 
Based on these data and on an extensive review of the MDMA literature, we conclude 
that MDMA-assisted psychotherapy may have the potential to serve as a novel treatment 
for chronic PTSD, and that the modest risks of administering MDMA within a 
therapeutic context are greatly outweighed by the possibility that this treatment may offer 
significant benefits.  
 
Methods 
 
General Study Design 
 
Twenty-one individuals with chronic PTSD will be recruited for a double-blind, placebo-
controlled pilot study in which MDMA or placebo is administered in the context of 
ongoing psychotherapy. The first 20 individuals will have treatment-resistant PTSD, and 
the additional participant will be a veteran with war-related PTSD that has lasted for at 
least a year but no longer than five years. This last subject will not be required to be 
treatment resistant if he has been unable or unwilling to undergo conventional therapy. 
Twelve participants will be randomly assigned to receive MDMA, while eight 
participants will receive inactive placebo. The additional participant will be randomly 
assigned to receive MDMA or placebo, with a 60% chance of receiving MDMA anda 
40% chance of receiving placebo. Following baseline measures and two introductory 
psychotherapy sessions, participants will receive two MDMA or placebo-assisted 
sessions spaced 3-5 weeks apart. During these two experimental sessions, participants 
will receive an initial dose of 125 mg MDMA followed by a supplemental dose of 62.5 
mg MDMA, or they will receive initial and supplemental doses of inactive placebo. 
Participants assigned to receive MDMA will undergo a third “open label” session as soon 
as can be arranged after the blind is broken for the participant 2 months after the second 
experimental session. Participants assigned placebo who choose to enroll in “Stage 2” 
will undergo three open-label sessions scheduled as indicated in the tables below. One 
day after each experimental session, a non-drug psychotherapy session will occur. In 
addition, three or four non-drug psychotherapy sessions will be conducted between the 
two experimental sessions, three or four non-drug psychotherapy sessions will be 
conducted after the second experimental session, and three non-drug therapy sessions will 
be scheduled after the third “open label” session. Outcome measures will be administered 
two months after the second MDMA or placebo session in Stage 1 and four to six weeks 
after the second MDMA session in Stage 2. A final data-collection session will take place 
at two months after the third experimental session. Participants who consent to the long-
term follow-up scheduled to occur at least ten months after completing the study will be 
assessed with the CAPS by the independent rater and will complete a questionnaire 
assessing the impact of study participation.  

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  8 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
Schedule of Visits: Stage 1 
Time: 
p=post 
d=days 
w=week 
m=month 
Before Visit 
4 
Aft
er 
Eli
gibi
lity 
Aft
er 
V. 4 
 
1
d 
p 
v
5 
3-
7d 
p v 
5 
Between 
Visit 4 and 
Visit 11 
3-5 
w p 
visit
11 
1 d 
p v 
11 
3-7 
d p 
v11 
Between Visit 11 
and Visit 17 
2 m 
p  
v11 
Visit  
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
Pre- 
Study 
Screenin
g 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline 
Eval. 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Psycho 
Therapy 
 
x
x 
 
 
x
 
x
x
x 
 
x 
 
x 
x 
x 
x 
MDMA/ 
Placebo  
Session. 
 
 
 
 
x 
 
 
 
 
 
x 
 
 
 
 
 
 
Psycho 
Logical 
Measure 
x 
 
 
x 
 
 
x 
 
 
 
 
 
x 
 
 
 
x 
Neuro 
Psych. 
Measure 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
x 
Metaboli
c profile 
x+
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Electro- 
Lytes 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Liver 
FCT 
 
x 
 
 
 
 
 
 
 
 
 
 
 
x* 
 
 
 
 
Drug 
Screen &  
B-HCG 
x 
 
 
 
x 
 
 
 
 
 
x 
 
 
 
 
 
 
Medical 
exam 
x 
 
 
 
 
 
 
 
 
 
 
 
x 
 
 
 
 
Working 
Alliance 
Measure 
 
 
 
x 
 
x 
 
 
 
 
 
x 
 
 
 
 
 
RRPQ 
measure 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
+ =  Liver FCT included in metabolic profile for visit 1. 
* = ALT only unless otherwise directed by examining physician 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  9 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
Schedule of Visits – Stage 1 continued 
Time: p=post 
d=days, w=week 
m=month 
After 
V 17 
 1 d p 
v18 
Between v18 and 
v22 
2 m p  
v18 
10 m 
v. 18 
Visit  
1-18 
1-19 
1-20 
1-21 
1-22 
1-23 
Psycho 
Therapy 
 
x 
x 
x 
x 
 
MDMA 
Session 
x 
 
 
 
 
 
Psycho 
Logical 
Measure 
 
 
 
 
x 
x 
Drug Screen &  
B-HCG 
x 
 
 
 
 
 
**= Closing session 
 
Primary outcome measures were selected to be well-validated, clinically-relevant, and 
repeatable.  These include observer-rated measures of PTSD symptoms, subject-rated 
measures of symptoms and discomfort, and neuropsychologist-administered tests of 
neurocognitive function. Observer-rated and subject-rated measures of symptoms will be 
made at baseline, at four days after each experimental session, and at two months after 
the second experimental session.  Neurocognitive function will be assessed at baseline 
and at two months after the second experimental session.  A complete medical 
examination will be performed at baseline and at four days after the second MDMA or 
placebo session.  During experimental sessions, participants will be supervised at all 
times by trained medical personnel, including a physician who will be present throughout 
each experimental session.  Measures of physiological status and participant distress 
intended to monitor participant safety will be made at frequent, scheduled intervals. 
Participants who had received placebo during this study will be offered an opportunity to 
receive MDMA-assisted psychotherapy upon completion of the study. Participants who 
consent to the open-label continuation would receive two experimental sessions with 125 
mg MDMA, with experimental session scheduled 3 to 5 weeks apart. They would receive 
one non-drug therapy session prior to the first experimental session, non-drug therapy 
follow-up sessions after each experimental session, and a final follow-up scheduled two 
months after the second experimental session. Participants would complete outcome 
measures two months after the second experimental session.  
 
At least ten months after completing the study, defined as either completing Stage 1 or 
Stage 2, as applicable, consenting participants may take part in a long-term follow-up that 
will include re-assessment with CAPS and a questionnaire addressing the positive and 
negative effects of taking part in the study, any enrollment in new therapies, and use of 
“ecstasy” subsequent to study participation. The independent rater will conduct the  
CAPS assessment over the telephone and the questionnaires will be mailed to 
participants. 
 
Data Analysis 
 
The current study is a Phase II pilot study primarily designed to provide an estimate of 
the effect size of MDMA-assisted psychotherapy in relieving symptoms of PTSD.  As 
such, this study has sufficient power only to detect large effects.  However, it is 
hypothesized that participants receiving MDMA-assisted psychotherapy will tend to have 
greater decreases in observer-rated and self-rated symptoms and associated problems at 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  10 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
four days and two months after the final experimental session compared to participants 
receiving placebo.   
 
The first thirteen participants have been stratified prior to randomization according to 
whether or not they have been Dr. Mithoefer’s patients. Since it is unlikely that many 
more of Dr. Mithoefer’s patients will be enrolled in this study, stratification will cease for 
the last seven participants. Results will be analyzed for the entire 20 subjects, and they 
may also include the additional subject. A separate analysis will be conducted comparing 
results between those subjects who were Dr. Mithoefer's patients and those referred by 
other psychiatrists and psychotherapists. The purpose of this sub-analysis is to gather 
some information about whether subjects who have already established a therapeutic 
alliance with Dr. Mithoefer prior to the start of the study (his patients) will respond more 
favorably than the other subjects. 
 
Data will be analyzed by mixed analysis of variance (ANOVA), with experimental 
intervention condition (MDMA versus placebo) serving as a between-group factor and 
time of measurement, or experimental session (first or second) serving as within-subjects 
factors.  Statistical significance will be set at 0.05. Separate analyses will be performed 
for systolic blood pressure, diastolic blood pressure, heart rate, body temperature, 
Subjective Unit of Distress scores, the CAPS-2, the IES, the SCL-90-R, each RBANS 
scale score, the PASAT, and the Rey-Osterrieth Complex Figures Test scores.  Of these 
measures, it is expected that statistically significant changes will only be detected in heart 
rate and blood pressure and will last several hours when MDMA-assisted psychotherapy 
is compared to placebo psychotherapy sessions, but that no other statistically significant 
changes will be detected.  In particular, neurocognitive measures are not hypothesized to 
suggest potential toxicity in participants receiving MDMA. 
 
The statistics that we will be doing on this project are not complex given the small 
sample size.  Analyses will consist of descriptive statistics, inferential group 
comparisons, and exploratory correlations.  The first step will be to descriptively 
summarize the data.  We will quantitatively characterize the final study by obtaining 
mean scores and percentiles for all the variables, including the demographic 
characteristics and outcome variables.  The second phase of the data analysis will be to 
compare the control group with the experimental group.  We will perform some 
exploratory group comparison analyzes to determine if there are any systematic biases in 
the data. This is not expected to be the case, but since this is not a randomized design, the 
possibility exists.  In order to control for this possible confounding effect, we will use co-
variate statistical techniques if a systematic bias does exist.  Another method for 
controlling for any systematic bias is a repeated-measures design where subjects will also 
serve  as their own controls.  After the data has been summarized and reviewed, we will 
undertake the main statistical analyses.  A series of ANOVA's will be performed on our 
main outcome variables.  This will include the CAPS, Impact of Events, NEO, 
neurocognitive toxicity measures, biochemical markers, etc.  We will be using a mixed 
within/between analysis where the control group will be compared to the experimental 
group and where the subject's baseline will be compared with post treatment scores. We 
will perform exploratory analyses to compare participants who received supplemental 
doses with those who received single doses, and within/between analyses comparing 
PTSD symptoms after the second experimental session and the third, “open label” 
session. We will perform exploratory analyses that will compare the last CAPS score 
obtained during participation in Stage 1 and, if applicable, Stage 2, and CAPS score at the 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  11 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
long-term follow-up for any participants assessed at long-term follow-up. All of these 
analyses will be performed to test for our hypothesized outcomes.  Interactions in the data 
will also be investigated.  Finally, since this project is a pilot study, we will also perform 
exploratory data analysis in attempt to discover any finding that emerge outside of our 
predicted theories. 
 
Subjects  
 
Who and Why 
 
Participants will be unpaid individuals, male or female, ages 18 through 70, who have 
been diagnosed with current PTSD using DSM-IV criteria, including a score of 50 or 
above on the Clinician-Administered PTSD Scale (CAPS), a recognized measure of 
PTSD severity.  PTSD was selected for study because it is among the most debilitating of 
conditions for which there is evidence that MDMA may be effective.  There are only two 
FDA-approved treatment for PTSD (e.g., Zoloft and Paxil) and these treatments are not 
effective in all patients.  There is therefore a substantial need for improved treatments for 
this debilitating and degenerative illness.   
 
We will recruit twenty subjects who have failed to achieve remission after treatment with 
a selective serotonin reuptake inhibitor after at least three months, and after receiving 
psychotherapy lasting for at least six months, with at least twelve psychotherapy sessions 
in the course of treatment. We will also accept one veteran whose war related PTSD 
symptoms have lasted from a year to five years and who does not have access to 
conventional treatment or who refuses to undergo conventional treatment. Our intention 
is to recruit participants who, aside from having PTSD, are physically healthy, as 
confirmed by detailed medical evaluation, and will not be posed untoward risks by 
exposure to MDMA. Because of the high co-morbidity of mood and anxiety disorders 
among people with PTSD, it is necessary to include individuals with these additional 
diagnoses (excluding bipolar affective disorder).  As discussed below, we will only 
include persons  who are not taking or can be safely withdrawn from other prescription 
medications that might present difficult-to-evaluate risks of drug-drug interaction and that 
might confound any findings of therapeutic benefit.   
 
Total Number/Number per group 
 
Twenty-one men and women will be recruited for study participation.  The first twenty 
who meet inclusion criteria without any exclusion criteria will be included in the study. 
An additional subject will be a veteran who meets all other initial inclusion criteria but is 
unable to obtain psychotherapy and is unwilling to undergo pharmacotherapy. Any 
volunteers who drop out or are excluded between the first and the second experimental 
intervention (MDMA or placebo) sessions will be replaced.  Researchers will, 
nevertheless, attempt to collect outcome data on PTSD symptoms, neurocognitive 
function and the experience of being a research subject in drop-outs and excluded 
volunteers.   
 
Because no previous properly-controlled studies have assessed the efficacy of MDMA-
assisted psychotherapy, this pilot study is necessary to estimate the effect size this 
experimental intervention so that we may later design a larger, properly-powered study.  

 
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Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
This pilot study will also allow the researchers to evaluate the instruments used for 
outcome measures and the timing of these measures.  We recognize that this study is 
under-powered for all but large effects and that trends seen in this study must be 
interpreted with caution. This pilot study will be followed by a second pilot study to 
further refine and standardize the therapeutic intervention prior to the initiation of any 
large Phase III trials. 
Inclusion/Exclusion Criteria 
 
Individuals will be included as potential participants if they meet the following 
conditions:   
 
1. Participants must meet DSM IV criteria for current PTSD (within the past 6 months) in 
response to crime victimization (CR-PTSD), including childhood sexual or physical 
abuse, or meet criteria for PTSD in response to combat, with the diagnosis lasting no 
more than five years in duration.  A subject would not be excluded for having more 
than one traumatic event, but would be excluded if a non-crime-related or non-
combat-related traumatic event were a significant contributor to the PTSD symptoms.  
They must have a CAPS score of 50 or higher, indicating moderate to severe PTSD 
symptoms.    
2. They must either: 
a. have had at least one unsuccessful attempt at treatment with a selective 
serotonin uptake inhibitor (SSRI) and one unsuccessful treatment with any 
form of psychotherapy for which there exist a controlled trial indicating 
efficacy in the treatment of PTSD.  This includes cognitive-behavioral therapy 
(including exposure therapy), stress inoculation training, including anxiety 
management, and insight-oriented psychotherapy (Foa et al. 2003; Jaycox et 
al. 2002; Krupnik 2002; Resick and Schenk 1992). Treatment with an SSRI 
must have lasted for at least three months, and psychotherapy must have 
lasted for six months and included at least twelve sessions.  Treatment will be 
deemed to have been unsuccessful if the participant continues to meet criteria 
for current PTSD following the treatment. 
b. Be a veteran with PTSD symptoms that have endured for no less than one year 
but no more than five years.  One such subject may be included without prior 
treatment if he or she is unwilling or unable to undergo psychotherapy or 
pharmacotherapy. 
3. Participants may also meet criteria for a mood disorder (except bipolar affective 
disorder, see exclusions) and for other anxiety disorders. The inclusion of subjects 
with other mood and anxiety disorders is essential because there is marked frequency 
of co-existence of other psychiatric disorders among people with PTSD (Brady et al. 
1994; Faustman and White 1989). 
4. Participants must also be willing to commit to medication dosing, experimental 
sessions, and follow-up sessions and to complete evaluation instruments. 
5. Participants must be willing to refrain from taking any psychiatric medications during 
the study period, with the exception of gabapentin when prescribed for pain control. 
If they are being treated with psychoactive drugs at the time they are recruited into 
the study, the prospective participant will be encouraged to discuss medication 
withdrawal with his or her outside treating physician, and will be required to give Dr. 
Mithoefer permission to do so as well. The drugs will then be tapered in an 
appropriate fashion to avoid withdrawal effects. They will be discontinued long 

 
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Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
enough before the first MDMA/placebo session to avoid the possibility of any drug-
drug interaction (the interval will be at least 5 times the particular drug's half-life). No 
new medications may be started until after the evaluation session, which will occur 2 
months after the second experimental session.  An exception to this may arise in the 
case of designated rescue medication that may be administered in the event of a crisis 
during the experimental session. 
6. Participants who are in ongoing psychotherapy at the time they are recruited into the 
study may continue to see their outside therapist during the course of the study. If 
they desire to do so, they must sign a release for the investigators to communicate 
directly with their therapist. They may not change therapists, increase the frequency 
of therapy or commence any new type of therapy until after the evaluation session 2 
months after the second experimental session.    
7. Participants must agree that, for one week preceding each MDMA/placebo session: 
c. They will refrain from taking any herbal supplement (except with prior 
approval of the research team)  
d. They will not take any nonprescription medications (with the exception of 
non-steroidal anti-inflammatory drugs or acetaminophen unless with prior 
approval of the research team). 
e. With the permission of their physician they will not take any prescription 
medications (with the exception of birth control pills, thyroid hormones or 
other medications approved by the research team). 
8. Participants must agree to take nothing by mouth except alcohol-free liquids after 
12:00 A.M. (midnight) the evening before each experimental intervention session. 
Participants must also refrain from the use of any psychoactive drug, with the 
exception of caffeine or nicotine, within 24 hours of each MDMA/placebo session. 
They must agree not to use caffeine or nicotine for 2 hours before and 6 hours after 
each dose of drug (MDMA or placebo). 
9. Participants must be willing to remain overnight at Dr. Mithoefer's clinic after each 
experimental session until the non-drug session occurring the next morning.  An 
attendant will be present to assist with personal needs if requested and offer dinner 
and breakfast. The attendant will be a registered nurse (RN) and of the same sex as 
the participant, and he or she will be trained for assisting in this study.  The attendant 
will be instructed to contact Dr. Mithoefer at the request of the participant or if there 
are signs that the participant is under physical or psychological distress. At the 
participant’s request and with Dr. Mithoefer's approval, a significant other can remain 
with the participant for support between the end of the experimental session and the 
non-drug session the next morning. 
10. Participants will be asked to locate an individual willing to drive them home the 
morning after the experimental sessions, after the non-drug therapy session. If a 
participant is unable to locate someone to transport them home, the investigators will 
assist the participant in obtaining transport from the clinic to the participant’s home or 
any other location where he or she is staying temporarily. 
11. Participants must be willing to be contacted via telephone on a daily basis by one of 
the investigators for a week after each experimental session.   
12. Female participants of childbearing potential must have a negative pregnancy test and 
must agree to use an effective form of birth control. 
13. Participants must be literate.  They must be proficient in reading documents written in 
English.   
 
Individuals will be excluded from study participation if they are: 

 
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Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
 
1. People who indicate that a non-crime or non-combat related traumatic event is a 
significant contributor to their PTSD symptoms, as assessed by the CAPS.  
2. Women who are pregnant or nursing, or of child bearing potential and are not 
practicing an effective means of birth control. 
3. People with a history of or current primary psychotic disorder or bipolar affective 
disorder type 1 or borderline personality disorder. 
4. People with dissociative identity disorder or an eating disorder with active purging, or 
borderline personality disorder.  
5. People with evidence or history of significant hematological, endocrine, 
cerebrovascular, cardiovascular, coronary, pulmonary, renal, gastrointestinal, 
immunocompromising, or neurological disease, including seizure disorder. 
(Participants with hypothyroidism who are on adequate and stable thyroid 
replacement will not be excluded). 
6. People with hypertension, peripheral vascular disease, hepatic disease (with or without 
abnormal liver enzymes), or history of hyponatremia or hyperthermia. 
7. People weighing less than 50 kg or more than 105 kg. 
8. People with prior use of "Ecstasy" (illicit drug preparations purported to contain 
MDMA) more than 5 times or at any time within the previous 6 months. 
9. People who would present a serious suicide risk or who are likely to require 
hospitalization during the course of the study. 
10. People requiring ongoing concomitant therapy with a psychotropic drug. 
11. People meeting DSM-IV criteria for substance abuse or dependence for any substance 
save caffeine or nicotine in the past 60 days. 
12. Any person who is not able to give adequate informed consent. 
 
Initial Contact Method and Informed Consent Process  
 
Potential participants will be recruited through referrals made by physicians or 
psychotherapists (see referral letter), including referrals selected from among the patients 
of Dr. Mithoefer, and advertisements.  Letters of referral specifically request the 
participation of crime victims experiencing symptoms of PTSD.  Prospective participants 
will contact the investigators for information about the research, usually initially by 
telephone.  Prospective participants will visit the researchers' office, discuss and review 
the study procedures (including risks, potential benefits, and alternatives) before giving 
written informed consent.  Individuals will be encouraged to ask questions and consider 
their alternatives.  The prospective participant’s comprehension of material in the 
informed consent will be assessed through a 16-item quiz administered after the 
prospective participant has read the consent form.  The investigators will address any 
misunderstandings identified through incorrect quiz responses, and will use the quiz as a 
guide for further discussion of the study if necessary.  Potential participants can include 
current and past patients of the researchers. Subjects from the researchers’ patient pool 
must have an interview with another psychiatrist not involved in the design or 
administration of the study before engaging in the informed consent process. The 
researchers will be careful when discussing the study with these individuals to ensure that 
the pre-existing patient-physician relationship does not unduly influence their decision 
concerning study participation. It is anticipated that this study will generate widespread 
interest and that potential participants from other regions may be willing to temporarily 
relocate in order to participate in the study.  We will accept no one who, because of 
illness, intelligence, language or cultural differences, appears unable to understand the 

 
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Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
nature and risks of the experiment, or who is unable to read (or, if blind, be read to) and 
follow the informed consent.   
 
Screening Process 
 
The 1998 version of the Clinician Administered PTSD Scale (CAPS: Blake et al. 1990) 
will be used to provide a DSM-IV CR-PTSD diagnosis.  Individuals with a score of 50 or 
above will be considered eligible for study participation (Weathers et al. 2001). If the 
subject meets DSM-IV PTSD criteria, the rest of the Structured Clinical Interview for 
Diagnosis  (First et al. 1994) wil7l be administered for the purpose of ruling out 
exclusionary Axis I diagnoses (i.e., exclusion criteria of substance dependence, psychotic 
disorder, dissociative disorder, eating disorder, or bipolar disorder).  Relevant modules of 
the SCID II (First et al. 1997) will be administered for the purpose of ruling out the 
presence of borderline personality disorder, an exclusionary Axis II disorder.   
 
Any subject who appears at imminent risk for trauma and victimization as assessed by 
information gathered during the screening assessment will be evaluated by the principal 
investigator (PI) or a study co-investigator.  He or she will be counseled in specific risk-
reduction strategies, and referred for immediate protection or care as needed.  These 
subjects would not be eligible for study participation.  Subjects who do not meet 
eligibility criteria at this point or who do not wish to participate will be referred for 
alternative treatment. 
 
There will be no gender exclusions or racial/ethnic exclusions.  Because the incidence of 
crime related PTSD is higher in women, it is anticipated that a majority of the subjects 
will be female.  We will attempt to recruit both men and women into this study.  
Similarly, it is anticipated that the racial/ethnic composition will be close to that of the 
regional population.  We will attempt to reach individuals of different ethnic or racial 
backgrounds in our recruitment efforts. 
 
Individuals who meet the psychiatric criteria and agree to participate in the study will 
receive further medical evaluation.  The examination will involve the following 
procedures: general medical history and physical exam, electrocardiogram (EKG), 
metabolic profile, assessment of serum electrolytes, thyroid hormone levels and levels of 
TSH, HIV serology and urine pregnancy test for females.  A physician not directly 
involved in administering the therapeutic treatments will perform the medical 
examination.  Results of HIV serology will be kept confidential, and appropriate referral 
for counseling will be made if necessary.   
 
After giving written informed consent to participate in the study, participants will receive 
information on a separate document concerning videorecording of study sessions. 
Participants can either consent or decline to consent to have their sessions recorded to 
video.  
 
Study Procedures 
 
Following pre-study evaluation, individuals who meet the study criteria and agree to 
participate will be scheduled for a baseline assessment battery to be administered within 
14 days prior to their first MDMA session.  They will also be scheduled for the two 
introductory psychotherapy sessions that will occur within this same time period. After 

 
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Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
these sessions, participants will receive MDMA or placebo during two experimental 
sessions. If both the participant and the principal investigator deem it is safe and 
appropriate to do so, participants will receive a supplemental dose of 62.5 mg MDMA or 
placebo approximately 2 to 2.5 hours after the initial dose. Experimental sessions will be 
followed by research follow-up sessions and psychotherapy follow-up sessions, as 
described below. 
 
Study Outcome Measures 
 
The measures that will be used in the course of this study are listed below.   
 
1. Clinician-Administered PTSD Scale, 1998 Revision. (CAPS: Blake et al., 1990). The 
CAPS is a structured clinical interview designed to assess the seventeen 
symptoms of PTSD along with eight associated features.  
2. Impact of Event Scale (IES; Horowitz et al, 1979). The Impact of Event Scale is a 22-
item self-report scale designed to measure the extent to which a given stressful 
life event produces subjective distress.  
3. Subjective Units of Distress. This is a standardized subjective rating scale by which a 
subject can quickly rate comfort level throughout the session (l-7 scale).  
4. Symptom Checklist 90-R: This is a standardized instrument used to measure subjective 
feeling states. It gives subscales on several dimensions.  
5. Working Alliance Inventory (WAI) (Horvath and Greenberg 1989) is a 36-item self-
report scale designed to assess the quality of working alliance existing between 
patient and therapist.   
6. Reactions to Research Participation-Questionnaire-Short Form (Revised) (Newman 
and Kaloupek, 2001).  This is a 24-item assessment of participants’ experience of 
study participation, reasons for participation, and perceived costs and benefits of 
participation.  The measure contains items addressing participation due to 
perceived coercion or undue influence by the investigators.   
7. Long-term Follow-Up Questionnaire: This is an 11-item questionnaire designed by the 
principal investigator (Michael Mithoefer MD) that assesses presence and 
perceived benefits of study participation, perceived harm from study participation, 
commencement of new psychotherapy or pharmacotherapy, and use of ecstasy 
subsequent to study participation. 
 
Neuropsychological Measures that will be used are: 
 
1. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) 
(Randolph 1997) has two parallel forms, with identical administration but 
different stimulus content, ideal for measuring change in neuropsychological 
status over time.  
2. The Paced Auditory Serial Addition Task (PASAT) (Roman et al. 1991) is a sensitive 
measure of information-processing speed and efficiency, concentration skills, and 
immediate memory which has an extensive literature associated with the effects 
of brain dysfunction. 
 3. Rey-Osterrieth Complex Figure (Mitrushina et al 1999) consists of a complex two-
dimensional line drawing. The subject's task is to copy the design with pencil on 
paper. The Rey-Osterrieth assesses visuoperceptual skills, spatial organizational 
skills and memory. 

 
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Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
 4. NEO Personality Inventory (Piedmont 1998). The NEO is a well-established measure 
of personality with sound properties of reliability and validity that operationally 
define personality structure according to a five-factor model.  
5. Subject Beliefs on Condition Assignment: All subjects will be asked to indicate 
whether they believe they have received MDMA or placebo during the 
experimental sessions.  
 
Safety Monitoring Measures that will be used are: 
 
1. Automated blood pressure and pulse monitoring equipment 
2. Thermometer for reading body temperature at regular intervals. 
3. Subjective Units of Distress, a 1-item self-report measure of subjective experience of 
degree of distress, with responses given via 7-point likert scale, with this short 
measure administered repeatedly throughout the MDMA/placebo session. 
4. Standard assay of liver enzymes (“liver panel”), assessed with blood sampled at follow 
up after the second MDMA/placebo session, as a means of detecting changes in 
liver function. 
 
As noted in discussing the specific hypotheses of the proposed study, the CAPS will 
serve as a primary outcome measure, and the IES and SCL-90-R serve as secondary 
outcome measures.  All measures of neurocognitive function and the NEO serve as 
means of safety evaluation.   
 
The Working Alliance Inventory (WAI) is intended to assess a process variable 
(therapeutic alliance) that may be related to efficacy. The Subjective Units of Distress 
(SUD) will also be administered in order to assess a process variable, subject comfort 
level throughout the experimental session. The Reactions to Research Participation-
Questionnaire-Short Form (Revised), another measure of a process variable, will be 
administered at the final follow-up to evaluate subject reactions to the study itself. The 
long-term follow-up questionnaire will be administered to assess any positive or negative 
effects of study participation and use of ecstasy subsequent to study participation. 
 
Baseline Assessment 
 
A battery of psychological and diagnostic assessments will be performed during the two 
weeks prior to the first experimental session in order to provide baseline measures of 
PTSD symptomatology, mood state and global functioning.  All study measures 
described above, except WAI and the measure of subject beliefs on condition assignment, 
will be administered during baseline assessments. 
 
Non-Experimental Psychotherapy Sessions 
 
Following the initial screening and data collection at baseline, all subjects will receive 
two ninety-minute introductory sessions with the therapists. The WAI will be 
administered during the second introductory psychotherapy session. There will then be 
two individual experimental sessions conducted 3-5 weeks apart, each lasting 
approximately six to eight hours depending upon the participant's response.  Three or 
four sixty to ninety-minute non-drug psychotherapy sessions will be conducted in the 
time intervening between the two experimental sessions.   Participants will also see the 
investigators in a ninety-minute follow up session a day after each experimental session, 

 
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Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
and in two or three more psychotherapy sessions after the second experimental (MDMA 
or placebo) session but before the study has been completed.  A final psychotherapy 
session will occur at the time of the final research follow-up two months from the second 
experimental session.  
 
Non-drug psychotherapy sessions will be recorded to video and audio. These recordings 
will be used for manual development and potentially for training therapists to perform 
MDMA-assisted therapy. They are intended to record the events occurring during 
therapy, and will not serve as outcome measures. Full names and addresses, if they 
appear in these recordings, will be edited out of the recording before the tape is seen by 
anyone other than the study participant and the investigators present at the session. Facial 
images will not be removed from the video tapes to be viewed by the sponsor or 
investigators for review of the therapeutic process and for manual development.  
However face shots will be obscured on any tapes used for training purposes unless the 
subject gives his or her written permission (via "Video and  Audio Use Permission IC”) 
to retain face shots (for more details of recording, see Appendix B). 
 
The attendant referred to above will be an RN, will always be of the same sex as the 
subject he or she will be staying with, and will be trained by Dr. Mithoefer to be on duty 
at the office following each experimental session.  The attendants will be selected for 
their ability to act as reliable and compassionate attendants to the study subjects, and to 
recognize when to call Dr. Mithoefer in the event that a subject is experiencing physical 
or emotional distress during the night following an experimental session.  A necessary 
quality for these individuals will be the ability to tolerate being in the presence of other 
people’s emotions without becoming emotionally reactive themselves. Attendants will be 
taught to be attentive to the subject's needs for food or liquids, and to offer 
companionship by sitting with them or taking a walk according to the subject's desires.  
They will be instructed to listen compassionately if the subject wants to talk, but not to 
attempt to interpret the subject's experiences or otherwise act as therapists.  The emphasis 
will be on listening rather than talking and on being quietly present.  The attendant will 
be taught to avoid initiating long conversations with the subject or being intrusive in any 
way on the subject's experience, other than to inquire about their physical or emotional 
needs and their comfort. This role will be further described below under 
Psychotherapeutic Procedures during Experimental Session. 
 
Sessions Employing the Experimental Intervention 
 
Drugs and Dosing 
 
Twelve individuals will receive 125 mg MDMA and eight individuals will receive lactose 
placebo in gelatin capsules on two occasions, 3-5 weeks apart. The additional participant 
enrolled in the study will have a 60% chance of receiving 125 mg MDMA. An initial 
dose of 125 mg MDMA has been selected for use in this study on the basis of prior 
reports of therapeutic effectiveness and tolerability. Doses equal to or greater than 125 
mg have been well-tolerated in previous studies of MDMA in humans (Cami et al, 2000; 
Freedman et al. 2005; Grob et al, In preparation; Harris et al. 2002; Lester et al. 2000; 
Mas et al, 1999; Tancer et al, 2001; Tancer et al. 2003; Vollenweider et al. 1998). The 
supplemental dose of 62.5 mg was chosen on the basis of prior reports of such doses 
extending potentially therapeutic effects of MDMA in psychotherapy (Stolaroff 2004) 
and in an uncontrolled study (Greer and Tolbert 1986). The cumulative dose of 187.5 mg 

 
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Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
has been exceeded by single doses in some previous research studies without any adverse 
events (Grob et al., unpublished see p. 52 of initial submission to FDA, IND #63,384). 
MDMA will be supplied by David Nichols, Ph.D., Department of Medicinal Chemistry 
and Pharmacognosy, Purdue University.  This MDMA is of confirmed identity and purity 
and has been used in all three Phase I clinical trials conducted in the United States.   
 
Currently three studies of MDMA-assisted psychotherapy will use supplemental dosing. 
This includes two studies of MDMA-assisted psychotherapy in people with PTSD. One 
study is to take place in Israel and has gained final approval from the Israeli Ministry of 
Health, an Israeli ethics committee, and the Israeli Anti-Drug Authority. The other study 
will take place in Switzerland. The protocol and informed consent have gained full 
approval from the local ethics board and the protocol design has obtained approval from 
the national health agency Swissmedic, with only the supply of MDMA remaining to be 
approved. Additionally, in December 2004, FDA permitted a study of MDMA-assisted 
psychotherapy in people experiencing anxiety as a result of advanced-stage cancer and 
short estimated life expectancy that will use supplemental dosing. 
 
Condition assignment will be randomized. The first thirteen participants have been 
stratified prior to randomization according to whether or not they have been Dr. 
Mithoefer's patients, but owing to the low likelihood of many other patients of Dr. 
Mithoefer’s being enrolled in the study, the last seven participants will not be stratified. 
The blind will be broken for each subject upon completion of the study. If there is an 
adverse event or other emergency, the blind may be broken for an individual participant.   
 
All experimental (MDMA or placebo) sessions will begin at 10:00 AM and will take 
place in the clinical treatment office of Dr. Michael Mithoefer, located in South Carolina.  
Participants will have had nothing by mouth except alcohol-free liquids since 12:00 AM 
the evening before. Participants will not have consumed caffeine or nicotine for two 
hours before or six hours after drug administration. They will be asked to arrive at 9:00 
AM for collection of a urine specimen for drug screening and, for females, a pregnancy 
test.  These results must be negative for the participant to continue with the experimental 
session.  Prior to drug administration, the researchers will verbally confirm that the 
participants have not recently ingested any medications (including herbal, over-the-
counter, or prescription) that are not approved by the researchers or allowed in the 
protocol.  After preliminary measurements (described in Monitoring for Acute Toxicity 
below) have been made and the researchers have discussed goals for this session and 
general procedures, participants will ingest gelatin capsules containing drug or placebo 
along with a glass of water. Subjects will remain overnight in the clinic until after the 
non-drug psychotherapy session the next morning.  A subject’s decision to withdraw 
from the study at any time will be respected as is accepted practice in human research. In 
the event of withdrawal during an experimental session the subject will not be permitted 
to leave the clinic until Dr. Mithoefer has assured that he or she is in a safe and stable 
condition.  Rules of withdrawal apply to the entire 2 experimental sessions while subjects 
are potentially on study medication.  If they do withdraw from study participation, they 
will not leave the clinic until the study staff feels it is safe for them to do so, and when 
they leave, a friend or family member will drive them home.  If transport is unavailable, 
the study staff will assist the subject in finding transport from the clinic.   

 
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Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
 
Measures during Experimental Intervention Session 
 
Measures made during the experimental sessions are primarily made for safety 
monitoring and are described below for “Monitoring for Toxicity.”  In addition, the 
investigators will make audio and video recordings of each experimental session.  
Comparison of information gathered from these recordings may be qualitatively or 
quantitatively examined in an attempt to gain a better understanding of the effects of 
MDMA within a psychotherapeutic context, but the recordings themselves will not be 
treated as outcome measures. Audio and video recordings will be used for manual 
development and potentially for training therapists to perform MDMA-assisted therapy. 
For more details on audio and video recordings, see Appendix B. 
 
Psychotherapeutic Procedures during Experimental Session 
 
The MDMA or placebo sessions will be supervised and facilitated by the principal 
investigator, male investigator/psychiatrist (Michael C. Mithoefer MD.) accompanied by 
an experienced female registered nurse (Ann T. Mithoefer.).  Both Michael and Ann 
Mithoefer will be present throughout the sessions. The sessions will be conducted 
following the principles developed by Stanislav Grof, MD for LSD psychotherapy (Grof, 
1980, pp. 123-147) and for Holotropic Breathwork (Grof 2000: pp. 178-183) and adapted 
for MDMA-assisted psychotherapy by Metzner and by Greer and Tolbert (Metzner and 
Adamson 2001; Greer and Tolbert 1998).  Both therapists have been trained and certified 
in Holotropic Breathwork facilitation by Grof, and have years of experience working 
therapeutically with this model in non-drug Holotropic Breathwork sessions. The 
principal investigator also has extensive experience treating PTSD in his psychiatric 
practice using both medications and psychotherapy.  More detail on the 
psychotherapeutic approach to be used in this protocol can be found in a treatment 
manual draft for MDMA-assisted psychotherapy (Ruse et al. 2002).  The protocols will 
be exactly the same for each experimental session.  
 
At the beginning of the session, the researchers will discuss with the subject his or her 
intentions for the session, including intentions regarding working with psychological 
issues related to their PTSD. After the session begins, subjects will recline in a 
comfortable position with eyes closed or wearing eyeshades if preferred. They will listen 
to a program of music designed to support their experience by initially aiding relaxation 
and later evoking and supporting deep emotions and the emergence of unconscious 
material. (Bonny and Savary 1990; Grof 2000: pp.186-191; Grof 1980; Unkefer 1990).  
After the first hour, if the participant has not spoken spontaneously, the investigators will 
check in with him/her about the nature of the experience. Approximately 2 to 2.5 hours 
after the initial dose, the investigators will assess whether a supplemental dose can be 
administered. If the investigators believe that it is safe and appropriate to do so, and if the 
participant agrees to a supplemental dose, then the participant will receive a supplemental 
dose of either 62.5 mg MDMA or placebo. The supplemental dose will be administered 
in the same manner as the initial dose.  For the rest of the experience, as appropriate, the 
investigators will engage with the participant to support and encourage emotional 
processing and resolution of whatever psychological material is emerging. The 
investigators will also encourage periods of time in which the participant remains silent 
with eyes closed and with attention focused inward in order to allow for the further 
unfolding of the inner experience.   

 
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Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
 
Electrolyte containing fluids will be available ad lib throughout the session within the 
limits described in “Monitoring for Toxicity."  Food will be available during the latter 
part of the session.  Foods provided will include crackers or bread, fruit and vegetables, 
and soups. After the conclusion of the session, dinner will be made available by the 
attendant, with breakfast offered the next morning. 
 
After approximately eight hours, if all medical parameters are acceptable and the subject 
is alert, ambulatory and emotionally stable, the session will be ended.  During the last 30 
- 60 minutes of the session, the attendant (an RN) will join the investigators and the 
subject in order to become familiar with the subject's state of mind, and any wishes the 
subject might have in the way of food or activity during the evening.  If the subject so 
desires, an additional designated support person (a spouse, partner, relative or friend) 
may join in this meeting.  After the researchers leave (when they have judged the subject 
to be emotionally and medically stable), the subject will spend the rest of the evening and 
night in Dr. Mithoefer's offices where he or she will have a private room to sleep in. The 
room will be an office designated for that purpose and will be furnished with comfortable 
furniture and a sofa-bed. All records pertaining to the study and any other sensitive 
material will be securely stored in a separate area of the clinic. The attendant will be on 
duty during this time and will have a separate room in which to rest.  The clinic has a 
kitchen with eating area, two bathrooms, several offices, and a yard with an outdoor table 
and chairs.  Since the office is in a quiet, attractive area, the subject, accompanied by the 
attendant, may spend time in the yard, walk in the neighborhood to enjoy nature.  
Subjects will, however, be encouraged to use much of the time for rest and for a period of 
reflection and integration in a quiet atmosphere.  The subject may request that a spouse, 
partner or friend also remain with them during the night, but this must be approved by Dr. 
Mithoefer after he has met this support person and has discussed the possible advantages 
and pitfalls with the study subject. 
 
During the night following the experimental session, Dr. Mithoefer will be at home 
within ten minutes drive of the office, and the attendant will be instructed to call him if 
the subject is experiencing emotional difficulties or any other problems.  Dr. Mithoefer 
will be willing to return to the office to meet additional needs or provide requested 
support to the subject, and will be available throughout the night of the experimental 
session.  (At all other times during the study the principal investigator or a covering 
psychiatrist familiar with the study will be on call 24 hours a day, seven days a week, to 
handle any concerns or emergencies related to the protocol. The participant will be given 
a wallet card with a pager number to call immediately if any problems occur.)  
 
When the researchers return to meet with the subject for the scheduled ninety-minute 
therapy session occurring on the following morning, the attendant will go off duty.  After 
this psychotherapy session, a person previously selected by the subject will provide a ride 
home. If the subject is unable to locate an individual willing or able to take them home, 
or if the designated person is unable to assist the subject due to unforeseen events, the 
investigators will assist the subject in finding an alternative means of returning home. 
 
Starting on the day of the non-drug psychotherapy session following each experimental 
session, one of the investigators will contact the subject via telephone on a daily basis for 
one week. The investigators will use clinical judgment to assess the psychological well-
being of the subject during this period of time.  If there are any indications of continuing 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  22 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
anxiety or distress, the investigators may arrange to work on reducing the distress at a 
specially scheduled  non-drug therapy session, through continuing contact, or at the next 
regularly scheduled non-drug therapy session.  The subject may also initiate contact with 
the investigators at any time throughout the study.     
 
Monitoring for Toxicity 
 
There is now a considerable body of information indicating that the likelihood of 
significant toxicity from the doses of MDMA used in this kind of setting is very low.  
Phase 1 studies conducted in the United States and Europe have failed to demonstrate 
toxicity (Cami et al. 2000; Grob et al. 1996; Harris et al. 2002; Lester et al. 2000; Liechti 
et al. 2001; Mas et al. 1999; Tancer and Johanson 2001; Vollenweider et al. 1998).  
Doses of up to 2.5 mg/kg were employed in one of the studies conducted in the US (Grob 
et al., In Preparation), with eight subjects receiving doses equal to or exceeding the dose 
of 125 mg proposed in this study. In another US Phase I study (personal communication, 
Tancer, 2001), over twenty subjects were administered doses larger than 125 mg.  
 
Likewise, psychiatrists in the US and Europe reported using MDMA in a large number of 
patients before the drug was made illegal.  The therapists did not report any severe 
adverse effects occurring during or after MDMA-assisted psychotherapy sessions 
(Adamson 1985; Greer and Tolbert 1986; Gasser 1994; Metzner and Adamson 2001; 
Widmer 1997).  
 
A controlled study of the effects of two doses of 100 mg MDMA given four hours apart 
failed to report any adverse events (Pacifici et al. 2002), and an uncontrolled 
psychotherapy study employed supplemental doses frequently half the size of an initial 
dose (Greer and Tolbert). Anecdotal accounts of psychotherapists who conducted 
MDMA-assisted psychotherapy prior to its scheduling indicate that supplemental dosing 
was used (Stolaroff 2004).  
 
Although serious untoward reactions are unlikely, the researchers will closely and 
continuously monitor participants during experimental sessions. To date, there have been 
no adverse events requiring the assistance of an additional emergency medicine physician 
occurring during any of the 31 experimental sessions. Of these 31 sessions, MDMA was 
administered in 23. All increases in blood pressure, pulse or temperature have resolved 
uneventfully without clinical intervention. The researchers have extensively 
communicated with the FDA to ensure that sufficient personnel and equipment are 
available to manage even very unlikely acute adverse effects.  Throughout all the 
sessions, participants will be attended by Michael Mithoefer, M.D., and Ann Mithoefer, 
BSN. Michael Mithoefer is board certified in internal medicine and psychiatry and is now 
re-certified in Emergency Medicine as of October 27, 2005.  He had previously been 
board certified in Emergency Medicine and practiced emergency medicine for 10 years 
before going into psychiatry.  Dr. Mithoefer also maintains Advanced Cardiac Life 
Support certification throughout the study. Ann Mithoefer was a nurse in a cardiac care 
unit before going into psychiatric nursing.  In addition, the researchers will hire a 
currently practicing emergency department nurse to be present in an adjoining room 
during at least the first five hours of each experimental session. The investigator, 
assisting investigator, and emergency medicine nurse will provide a team of one 
experienced emergency physician and two registered nurses to respond in the unlikely 
event of a medical emergency. 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  23 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
 
Blood pressure and pulse will be measured at the outset of each experimental session, 
once every 15 minutes for 6 hours, and then every 30 minutes for 3 more hours. If at any 
time the blood pressure exceeds 160 systolic or 110 diastolic or pulse exceeds 110, 
measurements will be taken every 5 minutes until the values fall below these levels or 
until they have been decreasing for 15 minutes or have stabilized at a level judged by the 
investigator to be safe. Body temperature will be measured at the outset and then hourly 
for 6 hours.  The physician may also call for more frequent measurements in the event of 
clinically significant changes.  The SUD (a brief self-report measure of volunteer 
distress) will be repeated at 60-90 minute intervals.  
 
Both non-drug sessions and experimental sessions will be conducted in the psychiatric 
offices of Michael Mithoefer MD.  The offices are located 2.6 miles from the nearest 
emergency room.  The office will be equipped with a "crash cart" containing the 
emergency drugs and equipment necessary to respond to any complications.  Benadryl, 
injectable epinephrine and other standard emergency drugs and equipment will be 
available on-site as a means of treating any potential allergic reactions or other medical 
emergencies.  Available emergency medications include antihypertensive agents (such as 
nitroprusside and labetolol), pressor agents, anxiolytics, and intravenous fluids. In 
addition to drugs, the crash cart will contain a defibrillator (with telemetry capability), an 
oxygen tank, a 12-lead electrocardiogram (EKG) device, a suction device, a pulse 
oxometer, an IVAC pump and intubation equipment (including laryngoscope, and 
endotracheal tubes).  We will have equipment for placing an arterial line and monitoring 
arterial pressure.  The researchers have established (in communication with the FDA) 
contingency plans for responding to those adverse events that appear most likely, based 
on a comprehensive review of case reports of toxicity in illicit MDMA users reported in 
the Investigator’s Brochure (See Appendix).  With these personnel and equipment, the 
researchers would be able to stabilize a subject in the office and then transport them by 
ambulance if hospital admission were required.  The researchers have contacted the 
Charleston County Emergency Medical Services and learned that, in 2001, the average 
response time for an ambulance to arrive at a location in the sector where the research 
will be conducted was 8 minutes, 55 seconds.  Transportation time to the East Cooper 
Medical Center Emergency Room should take no more than 10 minutes. 
 
An assay of the liver enzyme ALT will be performed at research follow-up four days 
after the second MDMA/placebo session so as to detect any change or decline in liver 
function.  Participants will be closely monitored for any change in emotional or cognitive 
function in the weeks following each session employing the experimental intervention.   
 
Written notice will be given to the IRB and the FDA within five days of the occurrence 
of a life-threatening adverse event, and within 15 days of the occurrence of any serious 
but not life-threatening events.   
 
The Data Safety Monitoring Board (DSMB) will be composed of three individuals, at 
least one of whom is psychiatrist and another a psychotherapist. The DSMB will have 
scheduled meetings after the first five subjects have completed their first experimental 
sessions, again after these same subjects have completed  their final follow-ups, after 
subjects 6-10 have completed their final follow-ups, and after subjects 11-15 have 
completed their final follow-ups. DSMB meetings will also be held to review every 
report of a serious adverse event, or more frequently if the DSMB so chooses. After each 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  24 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
meeting, the DSMB will present a report to the sponsor, the IRB and the FDA 
recommending whether the study should be continued as is, modified, or halted. Any new 
findings deemed relevant to study participation will be communicated to each potential 
participant during informed consent. 
 
We feel that these precautions and the contingency plans described in the appendix 
represent a very cautious approach to the remote possibility of a serious complication. 
 
Research Follow Up 
 
The follow-up will begin 3 to 7 days after the first experimental (MDMA or placebo) 
session.  There will be a total of three research follow-up interviews.  The first two will 
be done 3 to 7 days after the first and second experimental sessions, respectively. The 
CAPS, IES and SCL-90-R will be administered as outcome measures to be compared 
with baseline scores.  All outcome measures will be administered by Mark Wagner PhD, 
a consultant experienced in administering psychological and neurocognitive assessments.  
He will have no involvement in the experimental sessions and will be blinded to what 
occurs during the sessions.  A research follow-up will also be done at two months after 
the second experimental session.  The measures of cognitive function administered 
during baseline (RBANS, PASAT and Rey-Osterrieth Complex Figure) will be 
administered again at the last research follow-up, and the measures of PTSD symptoms 
will be administered again.   
 
The research and experimental intervention aspects of this project will be kept as separate 
and distinct as possible. Dr. Wagner, the psychologist obtaining all information gathered 
during research follow-up, will not be involved in monitoring the subjects during the 
experimental sessions, and will, therefore, be naïve to complaints of medication side 
effects.  He will also be blind to whether participants have been assigned to the MDMA 
or placebo condition.   
 
Participants will also be reassessed for psychological and physical status by the 
physician-investigator immediately following this session and weekly for at least 3 weeks 
after each session.   
 
Participants’ reasons for consenting to participate in the study, their experience during 
and after participation and perceived costs and benefits of participating will be assessed 
during the final research follow-up through the RRPQ, a self-report measure of responses 
to research participation.  Responses to this measure will be examined throughout the 
study to determine whether participants feel that they were unduly influenced or coerced 
into participating, and further actions will be taken to reduce undue influence if it is 
consistently detected through RRPQ responses.  
 
At the end of the study, participants will be asked to complete and sign a video recording 
permission form regarding whether or not they will allow people in sponsor's training 
program for teaching MDMA-assisted therapy to view video recordings of their session, 
with our without identifying information.  
  

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  25 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
Therapy Follow-up 
 
Participants will see the investigators one day after each of the two experimental 
(MDMA or placebo) sessions.  During these 90-minute follow-up sessions, participants 
will be encouraged to describe their experiences during the experimental sessions and to 
freely express any thoughts, feelings, questions or concerns they have.  The WAI, the 
measure of quality of working alliance administered during the second introductory 
session, will be administered again at each therapy follow-up session.  Participants will 
also be asked to indicate whether they believe they received MDMA or placebo at each 
follow-up session.  The primary purpose of these sessions will be to support the 
participant in further processing, understanding and integrating of the experience.  It will 
also be an opportunity for the investigators to gather information, in an unstructured 
format, about the effects of MDMA or placebo and to provide data with which to 
evaluate after the conclusion of the study whether the blind was maintained for subjects. 
 
Third Open-Label Experimental Session 
 
After each participant has completed the Visit 17 follow-up session, the blind will be 
broken for that subject, as per previous revisions of the protocol.  
 
• If a subject has received MDMA and has undergone both experimental sessions 
without any clinically significant adverse event, then the subject will be offered 
participation in a third, open-label, MDMA-assisted experimental session. 
Procedures for this third MDMA-assisted session will be the same as in the first 
two experimental sessions, except that all participants will receive MDMA. 
Subjects will undergo a therapy follow-up session 24 hours after the open-label 
MDMA-assisted therapy session identical to therapy-follow-up sessions occurring 
after other experimental sessions. Subsequently there will be two additional non-
drug psychotherapy sessions scheduled to occur approximately one and two 
weeks after the MDMA-assisted session to facilitate integration of material 
arising during the open-label session. These non-drug therapy sessions will follow 
procedures identical to those described for previous non-drug therapy sessions, 
except that participants will not complete the process measure of therapeutic 
alliance. All outcome measures will be administered two months after the open-
label MDMA-assisted psychotherapy session, including CAPS, IES and SCL90R. 
For the reasons detailed below, neurocognitive assessments will not be 
administered again.  
• Participants who receive placebo and enroll in the open-label continuation (“Stage 
2”) described below will be offered a third open-label session unless the 
investigators believe it is contraindicated or the participant declines. The third 
session will take place four to six weeks after the second open-label MDMA 
session. It will be preceded by one introductory session to re-acquaint the 
participant with study procedures, and it will be followed by non-drug 
psychotherapy follow-ups 24 hours, and approximately one week and two weeks 
later. PTSD symptoms will be assessed two months after the third MDMA 
session. In both cases, PTSD symptoms will be assessed four to six weeks after 
the second MDMA session.” 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  26 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
 
Open Label Continuation for Placebo Subjects  
 
Participants who received placebo during the course of the study may enroll in an open-
label continuation of the study wherein they will undergo three MDMA-assisted 
psychotherapy sessions and a continued course of therapy follow-up sessions. 
Participants will give written informed consent to take part in this second stage of the 
study, with consent given separately from the initial consent. If the participant consents to 
take part in this open-label continuation (or “Stage 2”) of the study, he or she would 
undergo three experimental sessions with an initial dose of 125 mg MDMA followed by a 
supplemental dose of 62.5 mg MDMA. The participant would undergo one preparatory 
non-drug psychotherapy session prior to the first experimental session, and he or she 
would receive non-drug psychotherapy follow-up sessions according to a similar 
schedule described for the first stage of the study. This schedule includes a non-drug 
psychotherapy session conducted a day after each experimental session, two non-drug 
psychotherapy sessions occurring between the first and second MDMA experimental 
sessions, and two non-drug psychotherapy sessions occurring within 3 weeks of the 
second MDMA experimental session. The final outcome measures from Visit 17 in the 
initial study would serve as baseline measures for the second stage (the open-label 
continuation), and outcome measures would not be repeated until two months after the 
second experimental session in the second stage of the study. An exception to this would 
be situations in which more than 30 days have passed between visit 17 and visit 18 (the 
first experimental session in the open-label continuation).  In this case outcome measures 
would be repeated in visit 17.1 as indicated in the table of visits for Stage 2 below. 
Participants will not receive a second medical examination after the second MDMA-
assisted session in Stage 2. Procedures for non-drug psychotherapy sessions, 
experimental sessions, weekly telephone contact and research follow-up sessions will be 
the same except that outcome measures will only be administered four to six weeks after 
the second experimental session and again two months after the third experimental 
session. Non-experimental and experimental sessions will be recorded to audio and 
video. These recordings will be used for manual development and potentially for training 
therapists to perform MDMA-assisted therapy. Full names and addresses are unlikely to 
appear on the video or audio tapes. However, if they do, they will be edited out. Face 
shots will not be excised from recordings viewed by the investigators or sponsor. (For 
more details on recording, see Appendix B.) Due to generally high scores found so far in 
participants completing Stage 1, the WAI, a process measure of therapeutic alliance, will 
not be administered again during Stage 2. Since performing a third neurocognitive 
examination is costly, and three forms do not exist for the RBANS so performance could 
reflect a learning curve produced from prior experience with the measures, 
neurocognitive function will not be assessed for a third time on the final follow-up.  
 
If, after the second open-label session of Stage 2, the subject has undergone both 
MDMA-assisted sessions without any clinically significant adverse events, then he or she 
will be offered participation in a third, open-label, MDMA-assisted experimental session. 
Procedures for this third session will be the same as for the previous two as described 
above. The third MDMA-assisted session will be scheduled four to six weeks after the 
second MDMA-assisted session. Follow-up non-drug psychotherapy visits will also be 
identical in procedure to previous psychotherapy follow-ups, including a non-drug 
therapy session occurring 24 hours after the MDMA-assisted session, and two non-drug 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  27 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
psychotherapy sessions, as described above.  Repeat outcome measures will be 
administered two months after the third MDMA-assisted session.  
 
Schedule of Visits-Stage  2    
Time: 
d=days 
w=week 
m=month 
p = post 
 
 
After 
v 17 
+ 1 d 
v18 
Between v18 
and v22 
3-5 w 
after 
v18 
+1 
day 
v22 
Between  
v22 and v27 
4-6 
w p 
v 
22 
4-6 
w p 
v 
22 
4-6 w 
p v 
22 
1 d 
p 
v27 
Between 
v27 and 
v31 
+8 w 
p v27 
Visit 
17* 
2-18 
2-19 
2-20 
2-21 
2-22 
2-23 
2-24 
2-
25 
2-
26 
2-
27 
2-28 
2-
29 
2-
29 
2-
30 
2-31 
Baseline 
Eval. 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Psycho 
Therapy 
x* 
 
x 
x 
x 
 
x 
x 
x 
 
x 
 
x 
x 
x 
** 
MDMA 
Session. 
 
x 
 
 
 
x 
 
 
 
 
 
x 
 
 
 
 
Medical 
Examinat
ion 
x^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Psycholo
gical 
Measures 
x 
 
 
 
 
 
 
 
 
x 
 
 
 
 
 
x 
*Participants enrolled in Stage 2 less than one month after completing Stage 1 will have their introductory 
psychotherapy session for Stage 2 at the final follow-up for Stage 1(visit 17), , and the PTSD symptom 
measures done in visit 17 will also serve as baseline measures for Stage 2. People starting Stage 2 more than 
one month after visit 17 will have an additional introductory psychotherapy session and will have PTSD 
symptoms measured during a separate visit scheduled after the final Stage 1 follow-up. The additional visits 
referred to above will be numbered 17.1 and 17.2 for the evaluation and the psychotherapy visits respectively 
** Closing session 
^ Only participants who have completed Stage 1 more than a month prior to being enrolled in Stage 2 will 
receive a second medical examination to ensure that they still meet subject eligibility criteria. 
 
Long-Term Follow-up 
 
Participants may take part in a long-term follow-up involving re-assessment of their 
PTSD symptoms and assessing the impact of study participation. The long-term follow-
up will be scheduled to occur at least ten months after completing Stage 1 for all 
participants in the MDMA condition and any in the placebo condition who did not enter 
Stage 2, and for at least ten months after completion of Stage 2 for all participants who 
took part in this open-label study continuation. The independent rater will re-administer 
the CAPS, and participants will complete the NEO, the IES, and a questionnaire 
concerning experiences since taking part in the study. The questionnaire will include 
questions about the presence, type and duration of perceived benefits to participating, 
presence and type of perceived harm from study participation, initiating new 
psychotherapy, new use of psychiatric medication, and any use of ecstasy after taking 
part in the study. The CAPS will be administered over the telephone or in person, and the 
questionnaires will be mailed to participants. Participants will be provided with a return 
envelope listing the principal investigator’s office postal address as both main and return 
address. The investigators will administer a separate consent for the long-term follow-up 
to all new participants on the final study visit of Stage 1 or Stage 2, and they will mail 
consent materials to all previous participants. The long-term follow-up will allow the 
investigators to assess the longevity of any changes in PTSD symptoms and to see how 
taking part in the study has affected participants’ lives. If there are any placebo 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  28 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
participants who decline to take part in Stage 2, the investigators can also make informal 
comparisons between those who received MDMA and those who received no MDMA 
during the study. 
 
Time and Events: M-P1 (63,384) Long-Term 
Follow-Up  
  
  
  
  
V1 
V2 
V3 
V4 
  
Pre-study 
Consent 
Questionnaires 
CAPS 
Assessment 
  
After main study 
  
After consent 
After 
questionnaires 
  
M. 
Ballard/Mithoefer 
M. Ballard 
M. Ballard 
Mark 
Check contact info 
X 
  
  
  
Mail Consent 
X 
  
  
  
Consent 
  
X 
  
  
Mail Questionnaires 
  
X 
  
  
Custom Questionnaires 
  
  
X 
  
NEO 
  
  
X 
  
IES 
  
  
X 
  
CAPS 
  
  
  
X 
 
Costs to Participants.   
 
There will be no costs to the study participants.  The sponsor will cover all costs of study 
participation.  Charges for treatment of the participant’s condition that are unrelated to 
the research study or any of its procedures will continue to be billed to the health 
insurance provider of the participant or to the participant him or herself.  It is anticipated 
that there will not be any charges for treatment that is unrelated to the study except in the 
case of participants who previously received therapy from the principal investigator and 
who will continue to receive ongoing treatment that is not related to participating in the 
study.   
 
Treatment and Compensation of Study Related Injury 
 
Treatment of a study-related emergency would first be billed to a participant’s health 
insurance provider.  The sponsor will cover any direct costs relating to the treatment of a 
study-related emergency that are not covered by a participant’s health insurance. Most 
study-related emergencies can be treated by the investigators as described under 
“Monitoring for Toxicity and within the Appendix.  If the investigator cannot treat a 
study-related emergency, then there are contingency plans for the transport of participants 
to the nearest hospital, East Cooper Medical Center.   
 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  29 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
Risks to Participants 
 
Risks and Discomforts Associated with Drawing Blood 
 
Blood specimens will be obtained from the subjects during the evaluation and follow-ups 
as listed above. Temporary discomfort may arise as a result of sampling blood.   
Participants may experience temporary discomfort at the blood drawing site.  There is 
also a remote possibility of inflammation or infection at the blood drawing site.  Blood 
samples will be used for the most part to determine whether the participant is healthy and 
can safely take part in the study.  Hence the temporary discomfort is outweighed by the 
need to ensure that participants are healthy, meet all inclusion criteria at screening, and 
are not experiencing adverse effects after the MDMA or placebo sessions.   
 
Risks and Discomforts Associated with Screening Procedure 
 
Medical data will be collected via history and physical examination, and via 
measurement of vital signs.  Submitting to a full medical examination may be time 
consuming, and may be distressing or uncomfortable for some.  Because medical 
examinations are part of the screening procedure, they cannot be omitted from the study 
design.   
 
Psychological and neuropsychological data will be obtained through interviews and 
neuropsychological testing.  Because these interviews require individuals to discuss their 
condition, they may prove upsetting for some.  Because psychiatric interviews and 
discussion of PTSD symptoms are used during screening, they cannot be avoided.  The 
investigators have experience working with people with PTSD, and they will seek to 
reduce anxiety and distress during these interviews.   
 
Risks and Discomforts Associated with Non-Experimental and Experimental 
Psychotherapy 
 
During non-drug and experimental sessions, participants will be asked to think about and 
discuss their thoughts and emotions relating to the traumatic event or events.  They may 
experience intense emotional responses to recalling and speaking about this material.  
Even in a therapeutic context, thinking about and discussing the trauma, symptoms 
related to the trauma or the effects of PTSD on life function can produce distress during 
and immediately after non-experimental and experimental sessions.  Psychotherapy is 
conducted as part of the research study, including the experimental intervention (MDMA-
assisted psychotherapy), and people undergoing psychotherapy are expected to confront 
unpleasant thoughts, feelings and memories in the process of therapy.  Because 
psychotherapy is an integral part of the research study design, the potential distress 
arising from psychotherapy is unavoidable.   
 
Risks and Discomforts Associated with the Experimental Intervention 
 
In doses similar to those proposed for this study, MDMA produces sympathomimetic 
effects similar to the effects of a moderate dose of methamphetamine or other stimulants 
(Cami et al. 2000; Grob et al. In Preparation; Grob et al. 1996; Harris et al. 2002; Lester 
et al. 2000; Liechti et al. 2001a; Tancer et al. 2002; Vollenweider et al. 1998).  The 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  30 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
amount of MDMA used in this study is not likely to produce changes in blood pressure or 
heart rate greater than 40% of resting values.  These changes should last no more than six 
hours.  These changes have been well-tolerated by volunteers in previous studies and 
should not pose large risks to our participants, who have been carefully screened for 
cardiovascular and related problems.  In less than 5% of volunteers, increases in blood 
pressure were higher.  Clinical intervention was not required in any of these cases.  
Nonetheless, careful monitoring of participants and predefined contingency plans will 
allow the researchers to rapidly identify and manage any related toxicity. 
 
MDMA also may produce mild alterations in perception and altered perception of time 
(Cami et al. 2000; Vollenweider et al. 1998).  Women may be more sensitive to these 
effects of MDMA (Liechti et al 2001a).  Some participants receiving MDMA report 
experiencing periods of increased anxiety (Harris et al. 2002; Tancer and Johanson 2001; 
Vollenweider et al. 1998).  Psychological distress could arise at any time after the onset 
of the effects of MDMA, from the first indications of drug effects until the last effects 
have dissipated (approximately 3 to 5 hours after drug administration).  Anxiety or 
distress may last for as little as 15 minutes or for as long as 5 hours.  In previous Phase I 
studies, these symptoms have been modest, self-limiting, and responded well to 
reassurance from investigators.  In the proposed study, participants will have the intention 
of confronting and working through traumatic experiences.  Hence signs of psychological 
distress, panic or other unpleasant psychological reactions are to be expected.   During 
the preparatory sessions, participants will be made aware of the fact that difficult 
emotions, including grief, rage and fear or panic, may arise during the MDMA sessions 
and should be understood as presenting an opportunity for addressing and dealing with 
these traumatic events.  If significant anxiety persists more than a few hours after the 
expected end of the experimental session, contingency plans (described in appendix) 
include the continued presence of the investigators, support and assistance provided by an 
individual close to the participant, and the possibility of administering anti-anxiety 
agents. 
  
Side effects of MDMA are modest and generally have not been associated with serious 
discomfort by volunteers in previous studies (Cami et al. 2000; Liechti et al 2001a; 
Tancer 2001; Vollenweider et al. 1998).  Decreased appetite, jaw clenching, and dry 
mouth are commonly reported during peak MDMA effects, while fatigue may be felt up 
to several days afterward. Less commonly, mild anxiety and depressed mood are reported 
one and three days after MDMA administration (Harris et al. 2002; Liechti et al. 2001a; 
Liechti et al. 2000b; Liechti and Vollenweider 2000a; b; Vollenweider et al. 1998).  
Some of these effects are very likely to occur, but proper preparation and follow-up 
support will reduce the difficulties participants might have with acute or sub-acute side 
effects, so that they will not be unduly troubled by them.   
 
MDMA may produce modest changes in immune functioning, lasting two to three days. 
A research team in Spain has studied the immunological effects appearing after the 
administration of one or two doses of 100 mg MDMA (Pacifici et al. 2000; Pacifici et al. 
2001).  They reported a decline in CD4 cells, smaller CD4/CD8 ratio, attenuated 
lymphocyte proliferation in response to mitogen, and an increase in natural killer (NK) 
cells, with effects diminishing but still detectable 24 hours after drug administration.  
MDMA decreased production of pro-inflammatory cytokines, including IL-2 and 
interferon-Gamma and increased production of anti-inflammatory cytokines, including 
IL-4 and IL-10.  Generally, MDMA appeared to decrease the concentration of Th1 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  31 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
cytokines and increase the amount of Th2 cytokines measured in blood. The mechanism 
of this MDMA-induced immunomodulation is unclear but may involve MDMA-induced 
glucocorticoid release or sympathomimetic activity.  Changes of similar magnitude and 
duration have been previously noted after ingestion of other psychoactive agents, such as 
alcohol or cocaine (Pacifici et al. 2000; Pacifici et al. 2001). Because of their limited 
duration, these changes are not likely to have clinical significance beyond a possibly 
increased risk of the common cold or similar illness for several days.  Previous Phase I 
studies have not reported any indication of increased risk of illness occurring after 
MDMA administration.  Individuals who are positive for HIV or have other 
immunocompromising diseases will be excluded from the protocol. 
 
MDMA may cause modest changes in cerebral blood flow lasting several weeks after 
drug exposure.  These changes have been hypothesized to be the result of short-term 
down-regulation of serotonergic receptors controlling cerebral vasodilatation (Reneman 
et a. 2002; Reneman et al. 2000).  MDMA induced decreased regional and global 
cerebral blood flow (CBF) 10 to 21 days after administration (Chang et al. 2000), as 
reported in a study of 10 ecstasy users given two separate ascending doses of MDMA at a 
two-week interval, with comparisons made at baseline and after the administration of 
both doses.  Doses per administration in this study ranged from approximately 17 mg 
(0.25 mg/kg) to approximately 175 mg (2.5 mg/kg).  The authors did not find differences 
in regional or global CBF when 21 MDMA-experienced volunteers (with a reported 211 
± 340 exposures) were compared to 21 nonusers (data are presented in the same paper), 
suggesting that effects on CBF do not last indefinitely.  There are no known 
consequences of these changes and neurocognitive performance was not altered in these 
volunteers.  
 
Serious MDMA toxicity is rare even in uncontrolled settings, considering the millions of 
users taking ecstasy of unknown identity, potency, and purity (Baggott, 2002; see 
Investigator’s Brochure). Many users routinely consume estimated MDMA doses that are 
several times higher than those proposed in the current protocol without any apparent 
toxicity. Under unsupervised and nonmedical conditions, the most common serious 
adverse event involves hyperthermia, which often appears to be influenced by prolonged 
physical exertion (dancing) and other unsafe conditions of use, such as high ambient 
temperature. In addition to hyperthermic syndromes, other rare adverse events include 
dysphoric responses, hyponatremia, and hepatotoxicity. In the proposed clinical study, 
volunteers will be carefully monitored for signs and symptoms of these unlikely events.  
Contingency plans for responding to these events are described in an appendix.   
 
Risks posed by MDMA to pregnant women are not known.  One of two studies of ecstasy 
users suggests that use of ecstasy and other drugs during pregnancy may be associated 
with some abnormalities at birth, but the meaning of these findings are in dispute. 
Women who are able to bear children will be required to use effective contraception 
during the study and pregnant women will be excluded from participation, with 
pregnancy tests performed before each drug administration. 
 
MDMA is classified as a Schedule I compound, largely on the basis of its growing 
popularity at night clubs and parties in the early to mid-1980s.  Whether or not MDMA’s 
abuse potential will negatively affect people with PTSD exposed to MDMA when given 
along with psychotherapy is an open question for which there is no direct data.  However, 
instead of experiencing euphoria, people with PTSD undergoing MDMA-assisted 

 
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Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
psychotherapy during the experimental sessions are likely to experience painful and 
frightening emotions and memories related to the original traumatic incident.  As a result, 
it seems unlikely that people with PTSD undergoing this emotionally challenging 
experimental intervention will find the experience pleasurable or safe enough to pursue 
MDMA use in unsupervised and uncontrolled settings.   
 
There is no evidence that MDMA-naïve healthy volunteers exposed to MDMA in 
previous Phase 1 clinical studies have been motivated to seek out and use MDMA in non-
medical settings.  For example, Liechti et al. (2001) reviewed the effects of MDMA in 54 
male and 20 female volunteers who had participated in clinical studies.  Liechti and 
colleagues stated that “none of the participants expressed any interest in taking MDMA 
as a recreational drug” after participation in an MDMA study.   
 
There is known to be significant comorbidity for substance abuse among individuals with 
PTSD, though specific data on the relationship between MDMA use and PTSD have not 
been reported. Currently, there is no definite evidence concerning the causal relations 
between the two disorders, and it is unclear whether PTSD precipitates substance abuse 
or whether people with pre-existing substance abuse are at greater risk for PTSD.  The 
most commonly accepted hypothesis for the relationship between PTSD and substance 
abuse is that of self-medication (Meisler, 1996).  Since individuals undergoing the 
proposed experimental intervention will be encouraged to confront traumatic events 
during the experimental intervention rather than defending against them or avoiding 
them, it seems likely that these individuals will subsequently be less inclined to choose to 
self-medicate through the self-administration of MDMA.  
 
In the currently proposed study, diversion is not an issue because MDMA will only be 
administered under supervision of a psychiatrist and no take-home doses will be 
permitted.  MDMA will be handled following all regulations pertaining to the handling 
and dispensing of controlled substances within research studies.   
 
Potential Neurotoxicity Associated with Ecstasy Use 
 
Extensive studies in animals indicate that high or repeated dose MDMA exposure can 
damage serotonergic axons originating in the dorsal raphe nucleus of the 
brainstem, probably as a result of oxidative stress, and this damage is associated with 
decreases in serotonin, serotonin metabolites, and serotonin transporter site density (See 
Baggott and Mendelson 2001; Green et al. 1995; O’Callaghan and Miller 1994 and 
Chapters 4 and 5 in the Investigator’s Brochure).  Although some regrowth occurs, 
seemingly permanent redistribution of axons was noted in a study with squirrel monkeys 
(Hatzidimitriou et al. 1999).  Similar changes can be induced by methamphetamine and 
some other psychostimulants (Miller and O’Callaghan 1996; Molliver et al. 1990; 
O'Callaghan and Miller 1994; Sabol et al. 1995; Seiden and Kleven 1989; Seiden and 
Sabol 1996). There is controversy over the extent to which analogous changes occur in 
humans. Imaging studies comparing ecstasy users with non-users have found evidence of 
lower binding to serotonin transporter re-uptake (SERT) sites (McCann et al. 1998; 
Obrocki et al. 2000; Reneman et al. 2001a; Reneman et al. 2001b; Semple et al. 1999).  
Because these studies use novel experimental techniques to compare self-identified drug 
users and non-users, it is not always clear what is being measured or how apparent 
differences relate to MDMA exposure (Kish 2002).  More importantly, there has been no 
evidence of these changes in clinical studies.  Vollenweider and colleagues measured 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  33 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
serotonin transporter density using positron emission tomography (PET) with the same 
radioligand employed in one of the previous studies [11 C]McN5652 (McCann et al. 
1998) before and after a clinical administration of approximately 105-120 mg (1.5-1.7 
mg/kg) MDMA (Vollenweider et al. 2001; 2000).  Comparisons were made in a pilot 
study with six MDMA-naïve healthy volunteers, and later in a second study with 
additional volunteers (n = 8).  Vollenweider and colleagues failed to find any lasting 
differences in scans made before and after MDMA administration.  These findings 
indicate that it is unlikely that MDMA will produce significant serotonergic toxicity at 
the dosage that will be used in the proposed study.   
 
If long-term serotonergic changes do occur in some humans, it is not known if these 
changes have clinically significant consequences.  Studies of illicit ecstasy users have 
suggested that repeated MDMA use may be associated with lowered neurocognitive 
performance, including measures of verbal memory (Bhattachary and Powell 2001; Bolla 
et al. 1998; Gouzoulis-Mayfrank et al. 2000; McCann et al. 1999; Morgan 1999; 
Reneman et al. 2000; Rodgers 2000; Zakzanis and Young. 2001a) and executive function 
(Gouzoulis-Mayfrank et al. 2000; Verkes 2000; Wareing et al. 2000; Zakzanis et al. 
2001b).  There is continuing controversy over whether these findings reflect pre-existing 
differences or the effects of other drug use (particularly cannabis).   The possible 
decreases are clinically insignificant, and do not appear to disrupt the lives of most 
ecstasy users examined in these studies.  As is also the case with imaging studies, 
conclusions drawn from examining regular ecstasy users may be inappropriately applied 
to the administration of one or two doses of MDMA in a controlled environment.  A yet-
unpublished study failed to find decreased memory in ecstasy users reporting a lifetime 
dose of 20 to 40 tablets, with decreased memory function only appearing in ecstasy users 
reporting a lifetime dose of 80 or more tablets (Gouzoulis-Mayfrank, data presented at 
the 2001 National Institute on Drug Abuse MDMA Conference).  A Phase I study 
comparing 14 ecstasy users at baseline and again after two separate administrations of 
MDMA, at doses per administration ranging from 0.25 mg/kg (approximately 17 mg) to 
2.5 mg/kg (approximately 175 mg) (combined dose of 0.75-4.75 mg/kg, or approximately 
52.5-332.5 mg) in a controlled setting failed to find differences between performance on 
an extensive battery of neurocognitive tests given at baseline and after MDMA 
administration (Boone et al. In Preparation, also see Investigator’s Brochure).  Measures 
employed in this study included assessments of verbal recall and executive function.  It 
would thus appear that while regular ecstasy use may be related to subtle decline in some 
areas of cognitive function, administration of MDMA at therapeutic doses does not 
appear to produce differences in neurocognitive function.  Lastly, some recently 
published studies failed to find reduced memory function in ecstasy users when compared 
with cannabis user controls (Simon et al. 2002).  Based on the above data, and additional 
data listed in the Investigators Brochure, it appears very unlikely that two doses of 125 
mg of MDMA will have any lasting untoward effect on neurological functioning.  
 
Some researchers believe that MDMA is neurotoxic in humans even at doses used in 
clinical trials (McCann et al. 2001).  Relying on a commonly used calculation for 
estimating pharmacological effects across species and data from studies in rats and 
monkeys, the researchers claim that humans should be even more sensitive to the effects 
of MDMA than smaller animals with higher metabolisms.  However, their use of 
interspecies scaling may be inappropriate in this case.  Interspecies scaling models may 
not be suited for estimating effects of extensively metabolized drugs, and there is some 
evidence that calculations using less than three different species are not as accurate as 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  34 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
those using three or more species (Mahmood and Balian 1996).  Vollenweider et al. 
(2001) compare published pharmacokinetic data for humans and rats and conclude that 
human exposure to MDMA after 125 mg is significantly less than the lowest known 
consistently neurotoxic MDMA dose in Sprague-Dawley rats, 20 mg/kg, sc, (Battaglia et 
al. 1988; Commins et al. 1987).  At these doses, human MDMA plasma area under the 
curve (AUC) are approximately 30% of the rat AUC.  Similarly, human Cmax are 
approximately 10% of rat Cmax.  The same research team that has used interspecies 
scaling to calculate a neurotoxic dose in humans has found no signs of neurotoxicity 
when 2.5 mg/kg was administered once every two weeks to squirrel monkeys over a 
period of four months (Vollenweider et al. 1999b, citing personal communication from 
Ricaurte to Swiss Federal Ethical Committee).  Taken together, these findings suggest 
that the dose of 125 mg MDMA is very unlikely to produce serotonergic neurotoxicity in 
humans.   
 
We have carefully considered the risks of such neurotoxicity and conclude that they are 
minimal in the proposed study. This conclusion is supported by empirical and 
toxicokinetic evidence and is consistent with the lack of toxicity reported in previous 
clinical MDMA studies.  Similar conclusions have apparently been drawn by the Food 
and Drug Administration, which has permitted this research and several Phase I clinical 
trials by other research groups in the United States.  Moreover, a series of letters in the 
journal Neuropsychopharmacology discussed the risks of neurotoxicity in MDMA 
studies (Gijsman et al. 1999; Lieberman and Aghajanian 1999; McCann and Ricaurte 
2001; Vollenweider et al. 2001; 1999a), leading two of the journal editors to conclude 
that there is no evidence that the MDMA exposures in the studies of Vollenweider and 
colleagues (similar to those currently proposed) were neurotoxic (Aghajanian and 
Lieberman 2001).  A team of researchers in Spain have also been permitted to conduct 
human trials with MDMA in the treatment of PTSD associated with sexual assault 
(Bouso 2001).    
 
Nevertheless, the risks of neurotoxicity arising from MDMA administration will be 
discussed with all participants prior to and during the informed consent process.  The 
investigators will monitor each participant for psychological and neurocognitive status 
throughout the study.   
 
Alternative treatments and procedures: 
 
The alternative to participating in the research study is to decide not to take part in the 
study.  The decision not to participate in this research study will not in any way alter or 
compromise the care offered to individuals receiving therapy from the investigator or any 
physician involved in this research study.   
 
The investigators will discuss alternatives to study participation, including other available 
treatments, with all potential participants.   
 
There are a number of recognized treatments for PTSD. Treatment often includes both 
psychotherapy and medication.  Most commonly recommended psychotherapeutic 
treatment for PTSD include anxiety management (stress inoculation training), cognitive 
therapy, exposure therapy and psychoeducation.  Psychodynamic psychotherapy and Eye 
Movement Desensitization and Reprocessing are also used to treat PTSD. 
 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  35 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
The only drugs that are currently FDA approved for treatment of PTSD are sertraline and 
paroxetine.  Sertraline has been shown to decrease the hyperarousal and avoidance 
symptoms, but not the re-experiencing symptoms, of PTSD.  Paroxetine has been shown 
to have an effect on all three categories of symptoms in approximately 62 % of patients.  
Other medications commonly used are other SSRIs, nefazedone, venlafaxine, tricyclic 
antidepressants, benzodiazepines, buspirone, zolpidem and mood stabilizers. 
 
The alternative to having non-experimental and experimental sessions recorded to video 
is not to consent to have sessions recorded to video disc. While audiorecording of 
sessions is included as part of study methods in the informed consent, consent to session 
videorecording is made on a separate document. 
 
Confidentiality of Records 
 
Every effort will be made to strictly safeguard the confidentiality of all participants.  
Despite this, privacy cannot be guaranteed.  Data collected from each participant will be 
identified only by the participant's initials on the source document and by a randomly 
generated numeric code on all secondary documents and databases.  Any materials or 
questionnaires mailed to participants will be sent along with stamped envelopes using the 
office address of the principal investigator both as main and return address, and 
questionnaires will only be marked with a newly assigned subject number, and 
participants will be instructed not to place their name on the questionnaire. The 
investigators will retain a key associating these new numbers with those assigned to 
participants upon study enrollment. All measures, records, audio and video recordings 
will be kept in a locked file drawer in a locked office.  Access to measures will be limited 
to regulatory agencies, researchers assessing the participant for changes in symptoms, 
and individuals analyzing data.  Researchers with access to data will not be provided with 
any information that would identify participants by name or by other means, such as 
social security number.  
 
Participants will sign forms for the release of information to any of the individuals who 
will need to obtain this information.  Interested parties might include the prescribing 
physician or psychiatrist.   
 
Removing identifying information from data and restricting access to researchers directly 
involved in assessing the participants should prevent the dissemination of confidential 
data, with or without identifying information.  Maintaining data in a secure environment 
will prevent the accidental or deliberate examination or removal of data.  While it is 
possible that individuals may be identified on audiotape or video recording through 
means other than their names, restricting access to audiorecordings or video recordings 
greatly reduces the opportunity for identification.    
 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  36 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
Risk-Benefits Analysis 
 
While there are a number of available means for the treatment of PTSD, the search for a 
wider array of potential treatments is crucial.  Not all individuals with PTSD respond to 
the currently available treatments.  MDMA-assisted psychotherapy may prove to be yet 
another treatment option for people with PTSD.  If it is found to be safe and efficacious 
in this population, then a potentially greater number of people will be able to improve 
their quality of life through the reduction or alleviation of PTSD symptoms.   
 
Our participants will be individuals suffering from PTSD that is refractory to treatment or 
who are unwilling or unable to attain or tolerate conventional PTSD therapies, and they 
will receive 10 to 11 non-drug psychotherapy sessions throughout the course of the study, 
in addition to the two experimental sessions.  Hence participants will not be denied an 
available treatment when taking part in this study.  If they are interested in doing so, 
participants who have yet to undergo other therapies prior to entry into this study may 
undertake those therapies after study completion. Some participants may be better able to 
tolerate MDMA-assisted psychotherapy than other psychotherapies. It is possible that, as 
hypothesized, MDMA-assisted psychotherapy will reduce PTSD symptoms. Since PTSD 
disrupts all aspects of life, including social and occupational function, even small 
decreases in symptom severity, frequency or intensity would benefit study participants. If 
this pilot study demonstrates improvement in PTSD symptoms, then future research may 
assist in the development of a novel treatment for PTSD.   
 
There is good evidence that administering two doses of 125 mg MDMA in a clinical 
setting poses a low risk to the subjects.  Previous studies examining the effects of MDMA 
in humans found that it has been well-tolerated, and no lasting toxicity has been reported 
in clinical trials with MDMA (Cami et al. 2000; Grob et al.; Grob et al. 1996; Lester et al. 
2000; Tancer et al. 2001; Vollenweider et al. 1998).  There is no evidence for long-term 
changes in serotonin function or neurocognitive function after a small number of MDMA 
administrations conducted during a clinical trial (Boone et al., In Preparation; 
Vollenweider, 2001; 2000).  Case reports of therapeutic work carried out before the 
scheduling of MDMA indicate that MDMA can be safely administered to people 
reporting symptoms of PTSD (Adamson 1985; Gasser 1994; Greer and Tolbert 1986; 
Grinspoon and Bakalar 1986).  In conclusion, MDMA has been safely administered in 
numerous Phase I studies of MDMA and in therapeutic settings, and low risks are 
presented by the administration of a small number of doses of MDMA in a clinical 
setting.   
 
Reports and anecdotal accounts indicate that, before MDMA was placed in Schedule 1, 
therapists conducting MDMA-assisted psychotherapy administered an additional dose of 
approximately one half the size of the initial dose to prolong the therapeutic effects of the 
drug (Stolaroff 2000), and this procedure was well-tolerated. Participants in an 
uncontrolled study of MDMA-assisted psychotherapy were offered a supplemental dose 
of MDMA during the course of therapy (Greer and Tolbert 1986). There is limited formal 
data concerning the risks associated with the addition of a second smaller dose of 
MDMA, but studies of the effects of two doses of 100 mg, either administered four or 24 
hours apart (Farre et al. 2004; Pacifici et al. 2001) suggest that a smaller supplemental 
dose would slightly elevate subjective and physiological effects. Prolonging the therapy 
session is expected to offer the potential benefit of improving PTSD symptoms, since 
there will be more time to rely on the anxiolytic and insight-fostering effects of MDMA. 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  37 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
The possibility of developing a novel means of reducing or alleviating symptoms in 
treatment-refractory posttraumatic stress disorder outweigh the low risks of three 
experimental sessions in a controlled laboratory setting, each administering 125 mg doses 
of MDMA with supplemental doses of 62.5 mg after 2 to 2.5 hours. 
 
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Appendix A: Procedures for Treating Serious Adverse Events 
 
Description of potential adverse events and procedures described to address these 
unlikely events are presented in order of relative likelihood.  Contingency plans for 
responding to these events were all negotiated with and approved by the FDA, and are 
described below.   
 
Hypertension 
 
Thus far, hypertension is the only adverse event to have occurred after the administration 
of MDMA in a controlled, laboratory setting (Grob et al. In preparation; Mas et al. 1999; 
Vollenweider et al. 1998).  Typical physiological effects of MDMA include modest 
elevations in blood pressure and heart rate, with blood pressure and heart rate returning to 
normal five hours after drug administration.  Clinically significant elevation in systolic 
blood pressure (30 mm Hg above baseline) has been recorded in less than 5% of 
volunteers across all human trials conducted so far.  Clinically significant increases in 
systolic blood pressure have lasted for up to two hours and have returned to normal 
without any intervention.  Clinically-significant elevation in blood pressure and heart rate 
usually begins 30 minutes to an hour after drug administration, and has lasted from 20 
minutes to 2 hours, with blood pressure and heart rate returning to normal within 
approximately five hours after drug administration.  None of the cases of elevated blood 
pressure have required medical intervention.   
 
Individuals with evidence of cardiovascular disorders, including hypertension, will be 
excluded from study participation. Blood pressure and pulse will be measured at the 
outset of each MDMA or placebo session, then once every 15 minutes for the first 6 
hours, and then every 30 minutes for the next 3 hours.  If at any time the blood pressure 
exceeds 160 systolic or 110 diastolic or the pulse exceeds 110, measurements will be 
taken every 5 minutes until the values fall below these levels or until they have been 
decreasing for 15 minutes or have stabilized at a level judged by the investigator to be 
safe.  During this time, the physician-investigator will continually evaluate the participant 
for increasing blood pressure and signs or symptoms of a developing hypertensive or 
other cardiovascular or neurologic emergency.  If needed, additional care will also be 
provided by the board-certified emergency room physician and licensed emergency room 
nurse who will be on standby in the next room.  The investigator will make a clinical 
judgment about whether additional monitoring or treatment is required.  If a participant 
exhibits systolic > 220 or diastolic > 120, he or she will be considered to be in 
hypertensive crisis, and will receive immediate treatment to lower blood pressure.  
Reasons for transport to the intensive care unit  (ICU) would include, but not be limited 
to, severe headache in the setting of hypertension, or angina or neurologic deficits 
regardless of blood pressure.  A crash cart will be immediately available and will contain 
nitroprusside and other antihypertensives in addition to the usual resuscitation drugs and 
equipment.  This will allow treatment to be instituted without transferring the participant 
if that should become necessary.  The physician-investigator may, at any time, make a 
clinical judgment to transfer the participant to the ICU in the nearest local hospital for 
further observation and care.   
 
Any participant who, during the first MDMA session, experiences sustained blood 
pressure of  > 220 systolic or > 120 diastolic or heart rate > 75% predicted maximum will 
not be given a second experimental session.   

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  45 
 
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Psychological distress 
 
Reports of MDMA-assisted psychotherapy conducted prior to the scheduling of MDMA 
indicate that some people receiving MDMA in a therapeutic context experienced periods 
of increased anxiety and even panic.  In the proposed study, participants will have the 
intention of confronting and working on their traumatic experiences and accepting and 
working through difficult and painful emotions.  Hence, signs of psychological distress, 
panic or other unpleasant psychological reactions are possible.  Psychological distress 
could arise at any time after the onset of the effects of MDMA until the last effects have 
dissipated (approximately 3 to 5 hours after drug administration), with anxiety or distress 
potentially lasting for as little as 15 minutes to as long as 5 hours.   
 
The potential for destabilizing psychological distress will be minimized by excluding 
people who might be more vulnerable to it (such as people diagnosed with bipolar 
affective disorder - 1 or with psychotic disorders), by preparing people before the 
experimental session, by creating an atmosphere of trust during the experimental session, 
by close monitoring, by daily contact with subjects for the period of a week after the 
experimental session, and by providing non-drug integrative psychotherapy sessions.  
Subjects will remain in the offices of the principal investigator for the evening and night 
of each experimental session.  The clinic will be staffed by a trained attendant (an RN) to 
respond to the needs of the subject. The attendant will be instructed to contact Dr. 
Mithoefer upon request or at the appearance of signs of a potential adverse event.  The 
overnight stay in a private room in Dr. Mithoefer's clinic and the presence of the 
attendant should further reduce psychological distress.  
 
People diagnosed with bipolar affective disorder – 1 or with psychotic disorders will not 
be enrolled in the proposed study.   
 
During the preparatory sessions, participants will be made aware of the fact that difficult 
emotions, including grief, rage and fear or panic, may arise during experimental sessions.  
Every effort will be made to help participants resolve difficult symptoms and to arrive at 
a more comfortable and relaxed state by the conclusion of the session, including empathic 
listening on the part of the investigators and performance of diaphragmatic breathing by 
participants.  
 
If, by the end of the 6 to 8 hour experimental session, the participant is still severely 
agitated or experiencing great psychological distress, the following measures will be 
taken:  
- If a subject is anxious, agitated, in danger of any self harm or is suicidal at the 
end of the MDMA/placebo session, the investigators will remain with the subject 
for at least two more hours.  During this time, the investigators will employ affect 
management techniques described in the manual, will talk with the subject to help 
him or her gain cognitive perspective of their experiences, and will help them 
implement the self soothing and stress inoculation techniques they were taught in 
the introductory sessions.  If this situation should occur at the end of one of the 
ninety-minute follow-up sessions at least one of the investigators will be available 
to stay with the subject for at least two additional hours. 
 

 
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- If a subject remains severely anxious, agitated or in danger of self harm or 
suicide, or is otherwise psychologically unstable at the end of this two hour 
stabilization period Dr. Mithoefer will decide between one of two options: 
 
A.  A psychiatric nurse, therapeutic assistant or therapist (whose 
availability we will have arranged ahead of time) , will stay with the 
subject until the time of his or her appointment with investigators the next 
day.  The investigators will then meet with the subject daily until the 
period of destabilization has passed.  At any time during this process, Dr. 
Mithoefer may make the clinical judgment to proceed to option B. 
 
B. Hospitalization for stabilization 
 
Participants hospitalized after a severe panic reaction will be suspended from study 
participation until after recovery or stabilization, at which time the investigator will 
carefully evaluate the subject's emotional status. If this response occurs during the first 
experimental session, the investigator may elect to forego the second administration and 
drop the subject from the study.  This decision will be made after discussion with the data 
safety monitoring committee and the submission of a report to the IRB and the FDA. 
 
For those subjects engaged in an on-going therapeutic relationship, we will actively 
involve their outside therapists in the management of any psychiatric complications of 
treatment.   
 
In the event of a participant’s experiencing severe, persisting emotional distress, such as 
panic attacks, severe generalized anxiety or insomnia following an MDMA session, the 
investigator may prescribe a benzodiazepine or zolpidem as a “rescue medication.”  If a 
participant should become psychotic or suicidal, arrangements will be made for him or 
her to be admitted to the nearest inpatient psychiatric facility of their choice.  Residual 
symptoms will be addressed during the frequent follow-up psychotherapy visits with the 
investigators.   
 
Angina or Myocardial infarction  
 
If a participant experiences ischemic type chest pain, whether or not it is associated with 
hypertensive crisis, he or she will receive oxygen and an IV and will be monitored as 
described above. He or she will be given nitroglycerin 0.4 mg SL q 5 minutes PRN chest 
pain pending transport to the hospital.  If further evaluation at the hospital reveals that the 
participant has had an acute myocardial infarction (AMI), he or she will be well within 
the time frame required for definitive therapy.  The American College of 
Cardiology/American Heart Association guidelines for the treatment of AMI recommend 
percutaneous transluminal coronary angioplasty (PTCA) as the treatment of choice when 
it can be performed within 90 minutes of arrival at the hospital in individuals who present 
within 12 hours of an episode of chest pain lasting more than 30 minutes and who have 
EKG evidence of AMI (J Am Coll Cardiol 34:890, 1999). 
 
Stroke 
 
If any participant has neurologic deficits, whether or not they are associated with 
hypertensive crisis, he or she will receive oxygen and an IV and will be monitored as 

 
MDMA-assisted Psychotherapy in Chronic PTSD 9/24/03, revised -01/23/2009  47 
 
Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
described above. He or she will be transported to the hospital for a head CT scan and 
further management.  If evaluation at the hospital reveals a nonhemorrhagic stroke, there 
will be time to administer recombinant tissue plasminogen within the 3 hour time frame 
recommended in the American Academy of Neurology/American Heart Association 
guidelines (Neurology 47:835, 1996).   
 
Hyponatremia 
 
Hyponatremia (low blood sodium or high blood water) has occurred after use of ecstasy 
in uncontrolled settings, perhaps as a result of MDMA effects and user behavior 
(drinking excessive water in order to stave off dehydration) (Henry and Rella 2001).  A 
modest dose of MDMA (47.5 mg) has been demonstrated to induce arginine vasopressin 
(AVP) release in humans (Forsling et al. 2001).  Researchers and therapists have not 
generally monitored for hyponatremia after MDMA administration.  However, 
hyponatremia has not been reported either in case reports of MDMA-assisted therapy 
conducted before the scheduling of MDMA or in recently conducted clinical trials.   
 
History of hyponatremia or detection of hyponatremia on initial physical examination 
will be cause for exclusion from the proposed study.  Participants will be given 
electrolyte solutions such as Gatorade instead of water in order to decrease the likelihood 
of dilutional hyponatremia.  They will not be allowed to drink more than 3 L. of fluids, 
and fluid intake will be appropriately spread out across the session.  If there are any signs 
or symptoms of hyponatremia, a stat serum sodium will be drawn and fluids will be 
withheld until the results are obtained.  If the serum sodium is less than 125mEq/L, serum 
and urine osmolality and sodium will be measured, and the subject will be transported to 
the East Cooper Medical Center, where further intervention can be provided.  
 
Hyperthermia 
 
Cases of hyperthermia in ecstasy users are probably due in large part to an interaction 
between drug effects, high ambient temperature found at some dance events and 
prolonged or vigorous exercise (Henry and Rella 2001).   No cases of hyperthermia have 
been reported in studies wherein MDMA was administered to humans in a controlled 
environment.  Hyperthermia is unlikely to arise in the proposed study because 
participants will not be exercising and will be in an environment with controlled ambient 
temperature, which will be kept comfortably cool.  
 
Body temperature will be taken every 60 to 90 minutes throughout each experimental 
session.  If temperature rises more than 1° C, attempts will be made to lower it by 
removing blankets and layers of clothing, decreasing the ambient temperature and, if 
necessary, directing a fan toward the subject.  If at any time the temperature rises more 
than 1.5° C above baseline despite these efforts, ice packs will be used, blood will be 
drawn for stat CBC, electrolytes, BUN, creatinine, glucose, CPK, PT, PTT, platelets and 
liver enzymes, and urine will be collected for urinalysis.  If there are significant 
abnormalities in these tests, if the temperature continues to rise, or if an elevated 
temperature is associated with delirium or muscle rigidity the participant will be 
transferred to the ICU at the East Cooper Medical Center.   
 
If, during the first MDMA session, a participant’s temperature rises more than 1 ° C. and 
does not rapidly come down after the above adjustments have been made in blankets, 

 
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Principal Investigator: Michael C Mithoefer. Sponsor: MAPS   
clothing, ambient temperature and ventilation, then that participant will not be given a 
second experimental session.     
 
In order to avoid dehydration, participants will be encouraged to drink at least 750 - 1500 
ml. of Gatorade or a similar fluid during the session depending on their size, level of 
activity and body temperature.    
 
Hepatotoxicity 
 
Cases of hepatotoxicity have been reported in ecstasy users, and in vitro studies show that 
MDMA can impair liver cell viability, with effects possibly exacerbated by hyperthermia 
(Carvalho et al, 1999), but their results suggest that this is very unlikely to occur in the 
proposed clinical study.  The peak liver exposure to MDMA in the proposed clinical 
study should be approximately one-eleventh the concentration shown to impair cell 
viability in these in vitro studies.  Hepatotoxicity has not been reported to occur in any of 
the clinical studies where MDMA was administered to research participants.   
 
Liver enzymes will be measured four days after the second experimental session as a 
means of monitoring for any signs of potential hepatotoxicity.  Any participant who 
shows abnormalities on any of the liver enzyme determinations will receive further 
evaluation and follow-up by a gastroenterologist.    
 
Reproductive/Developmental Toxicity 
 
One of two studies of polydrug-using ecstasy users found a possibly increased incidence 
of developmental abnormalities when pregnant women used illicit drugs including 
ecstasy (McElhatton et al. 1999).  There is some contention as to whether the 
developmental abnormalities reported in the study conducted by McElhatton and 
colleagues are, in fact, the result of ecstasy consumption.  Pregnant women will be 
excluded from participation in the proposed study and urine pregnancy tests will be 
performed before each drug administration. 

 
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Appendix B: Procedures used for Audio and Video Recording 
 
Recording to video will be done with two unobtrusive cameras operated remotely by the 
investigators, already present as co-therapists for the experimental and non-drug 
psychotherapy sessions.  One camera will be adjusted to capture a fairly tight shot of the 
subject, including full-face shots and partial or full body shots.  The other will capture a 
wider view including the subject and the two investigators.  Remote operation will 
include stopping and starting recording, as with a foot-operated switch or pedal. Two 
copies of the video tapes will be made routinely, one to be stored by the investigators, 
and the other by the sponsor. Both will be kept in locked cabinets in secure locations.  A 
third video tape copy will be made for any subject who requests it.   
 
Full names and addresses are unlikely to appear on the video or audio tapes. However, 
if they do, they will be edited out of the recording before the tape is seen by anyone other 
than the study participant and the investigators present at the session.  Facial images will 
not be removed from the copy of the video recording to be viewed by the sponsor or 
investigators for review of the therapeutic process and for manual development. However 
face shots will be obscured on any tapes used for training purposes unless the subject 
gives his or her written permission (via " Video and  Audio Use Permission IC”) to retain 
face shots. 
 
Audio recording of experimental and non-drug psychotherapy sessions will be done using 
a laptop computer controlled by one of the investigators, with control allowing him to 
stop or start recording.  The recordings will be written on an external hard drive 
connected to the laptop, not onto the laptop hard drive itself. The external hard drive will 
be kept in a locked office. The recordings will then be burned onto CDs in the 
investigators office. One copy will be stored by the investigators in a locked cabinet, 
another copy will be sent to the sponsor if requested and will also be stored in a locked 
cabinet at the location of the sponsor.  During experimental sessions, but not during non-
drug psychotherapy sessions, an additional audio recording will be made with a portable 
cassette deck.  The purpose of this is to enable the participants to have a cassette 
recording for themselves at the end of each experimental session, rather than having to 
wait until the CDs are made by the investigators.   
 
The participants will be informed on the consent document that they have the right to 
require audio and/or video taping to be stopped at any time and for any existing audio or 
video recordings to be erased.   
 
At the end of the study, participants will be asked to complete and sign a video recording 
permission form regarding whether or not they will allow people in sponsor's training 
program for teaching MDMA-assisted therapy to view video recordings of their session, 
with our without full facial images.