Cannabidiol in the Treatment
of Post-Traumatic Stress Disorder:
A Case Series
Lucas Elms, BS,
Scott Shannon, MD, FAACAP,
Shannon Hughes, PhD,
and Nicole Lewis, ND
Objectives: Cannabidiol (CBD) is a non-psychotomimetic cannabinoid compound that is found in plants of the
genus Cannabis. Preclinical research has suggested that CBD may have a beneﬁcial effect in rodent models of
post-traumatic stress disorder (PTSD). This effect is believed to be due to the action of CBD on the en-
docannabinoid system. CBD has seen a recent surge in research regarding its potential value in a number of neuro-
psychiatric conditions. This is the ﬁrst study to date examining the clinical beneﬁt of CBD for patients with PTSD.
Methods: This retrospective case series examines the effect of oral CBD administration on symptoms of
PTSD in a series of 11 adult patients at an outpatient psychiatry clinic. CBD was given on an open-label,
ﬂexible dosing regimen to patients diagnosed with PTSD by a mental health professional. Patients also received
routine psychiatric care, including concurrent treatment with psychiatric medications and psychotherapy. The
length of the study was 8 weeks. PTSD symptom severity was assessed every 4 weeks by patient-completed
PTSD Checklist for the DSM-5 (PCL-5) questionnaires.
Results: From the total sample of 11 patients, 91% (n=10) experienced a decrease in PTSD symptom severity,
as evidenced by a lower PCL-5 score at 8 weeks than at their initial baseline. The mean total PCL-5 score
decreased 28%, from a mean baseline score of 51.82 down to 37.14, after eight consecutive weeks of treatment
with CBD. CBD was generally well tolerated, and no patients discontinued treatment due to side effects.
Conclusions: Administration of oral CBD in addition to routine psychiatric care was associated with PTSD
symptom reduction in adults with PTSD. CBD also appeared to offer relief in a subset of patients who reported
frequent nightmares as a symptom of their PTSD. Additional clinical investigation, including double-blind, placebo-
controlled trials, would be necessary to further substantiate the response to CBD that was observed in this study.
Keywords: cannabidiol, cannabis, post-traumatic stress disorder, PTSD, anxiety, nightmares
Post-traumatic stress disorder (PTSD) is a relatively
common psychiatric condition with a lifetime prevalence of
6.1% in the United States.
PTSD often presents in clusters of
symptoms, including the re-experiencing of traumatic events
through intrusive memories and nightmares, avoidance of cer-
tain distressing factors, and alterations in mood, level of arousal,
and cognition. Psychotherapy is the established ﬁrst-line treat-
ment for PTSD, and various psychiatric medications are also
Rocky Vista University, Osteopathic Medical Student IV, Parker, CO.
Department of Psychiatry, University of Colorado Denver, Denver, CO.
School of Social Work, Colorado State University College of Health and Human Sciences, Fort Collins, CO.
Department of Naturopathic Medicine, Wholeness Center, Fort Collins, CO.
ªLucas Elms et al, 2019; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the
Creative Commons License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution,
and reproduction in any medium, provided that the original work is properly cited.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE JACM
Volume 00, Number 00, 2018, pp. 1–6
Mary Ann Liebert, Inc.
typically employed. The development of additional treatment
agents is important because current medications, including se-
lective serotonin reuptake inhibitors, serotonin/norepinephrine
reuptake inhibitors, antiadrenergic agents, and second-
generation antipsychotics, have questionable efﬁcacy and
often carry signiﬁcant undesirable side-effect proﬁles.
Although the pathophysiology of PTSD has not yet been
deﬁnitively described, a number of factors are suspected to
contribute to the development of this disorder. One hy-
pothesis relates PTSD to dysregulated memory retrieval
through the process of reconsolidation and impaired ex-
tinction of aversive memories.
The endogenous cannabi-
noid system has been shown to play an important role in the
process of aversive memory extinction through the activity
of central CB1 receptors.
Two cannabinoid receptors are
known to exist in the human body: CB1 and CB2 receptors.
CB1 receptors are located mainly in the brain and modulate
neurotransmitter release in a manner that prevents excessive
neuronal activity, thus calming and decreasing anxiety. CB1
receptors also have a role in reducing pain, inﬂammation,
regulating movement and posture control, and regulating
sensory perception, memory, and cognitive function.
Cannabidiol (CBD) is known to have multiple physio-
logic mechanisms of action, including 5-HT
agonism, adenosine and opioid receptor modulation, acti-
vation of the endogenous endocannabinoid system, antago-
nism at GPR55 receptors, and activation of transient
receptor potential channels.
CBD’s activity at 5-HT
receptors may drive its neuroprotective, antidepressive, and
anxiolytic beneﬁts, although the mechanism of action by
which CBD decreases anxiety is still unclear.
shown to be helpful for decreasing anxiety through a sim-
ulated public speaking test at doses of 300–600 mg in single-
Other studies suggest that lower doses of
10 mg/kg have a more anxiolytic effect than higher doses of
100 mg/kg in rats.
Of particular interest to this study is the effect of CBD on
the endogenous cannabinoid system. CBD has minimal af-
ﬁnity for CB1 and CB2 receptors,
but it does indirectly
cause activation of CB1 receptors by increasing the avail-
ability of endogenous endocannabinoids. Anandamide is an
endogenous cannabinoid that acts as a partial agonist at CB1
receptors. It is metabolically deactivated by the enzyme
fatty acid amide hydrolase (FAAH). CBD has been shown in
some studies to inhibit FAAH, thus increasing the avail-
ability of anandamide and causing activation of the en-
Studies in rodent models have
shown that pharmacologic activation of the endocannabinoid
system through CB1-receptor agonist agents leads to de-
creased behavioral response to aversive memories in rodent
models through the inhibition of memory reconsolidation
and enhanced extinction.
This early research suggests
that agents such as CBD that cause indirect activation of
the endocannabinoid system may have utility in the treatment
Current evidence regarding the use of CBD for PTSD in
humans is minimal. One case report showed that adminis-
tration of 12–37 mg of oral CBD daily was associated with a
reduction in anxiety symptoms and sleep disturbances in a
10-year-old patient with PTSD due to sexual trauma.
Another study showed that 32 mg of inhaled CBD resulted
in consolidation of aversive memory extinction and atten-
uation of explicit fearful responding in healthy human
See Bittencourt and Takahashi
for a recent
comprehensive review of pre-clinical and clinical studies
regarding the relationship of CBD to PTSD. To date, no
clinical trial evaluating the effectiveness of CBD in reduc-
ing symptoms of PTSD in humans has been completed.
The hypothesis of this study was that patients with DSM-
5-diagnosed PTSD who were administered CBD along with
routine psychiatric care would show a decrease in PTSD-
speciﬁc symptomatology. This hypothesis was based on
prior rodent and limited human studies that suggest that (1)
CBD may cause decreased response to and increased ex-
tinction of aversive memories, and that (2) CBD may have
an anxiolytic effect, which, in turn, would have therapeutic
value in patients with PTSD. To this end, we conducted a
retrospective ﬁle review of adult patients with PTSD who
were treated with CBD as part of standard psychiatric care
in an outpatient clinic. The goal of this review was to ex-
amine the tolerability of CBD and its effectiveness in PTSD
Materials and Methods
Design and procedures
This article describes a retrospective chart review of adult
psychiatric patients with a diagnosis of PTSD who con-
sented to treatment with CBD as augmentation to routine
psychiatric treatment at an outpatient psychiatric clinic. All
current patients with a diagnosis of PTSD were considered
for treatment with CBD between February 2016 and May
2018. Patients were not excluded based on the presence
of other psychiatric comorbidities (aside from an active
thought disorder) or concurrent use of cannabis. The diag-
nosis of PTSD was established through clinical evaluation
by a mental health professional (psychiatrist, psychiatric
nurse practitioner, or physician assistant). Inclusion criteria
for the present analysis required a cut-off score of 33 on the
Post-Traumatic Stress Disorder Checklist for the DSM-5
and a minimum of two consecutive follow-up
appointments after the initial intake appointment. The ﬁnal
sample consisted of 11 adult patients with a diagnosis of
PTSD and who met inclusion criteria.
After the initial baseline assessment, PCL-5 assessments
were completed by patients every 4 weeks to monitor
changes in the severity of PTSD symptoms. In addition to
CBD, patients also received routine treatment in the form of
psychiatric medications, various psychotherapy modalities,
and standard integrative treatments, as indicated for their
diagnoses of PTSD and other psychiatric comorbidities.
These integrative treatments often included dietary changes,
herbal supplementation, neurofeedback, and intravenous
infusions of vitamins and minerals.
Four patients received CBD as an oral capsule only. One
patient only received CBD in the form of an oral liquid
spray. Fifty-ﬁve percent (n=6) of patients received both
forms of CBD either concurrently or sequentially over the
course of the study. The form of CBD (capsule vs. liquid
spray) was determined by provider and patient preference.
The CBD products used in this study were supplied by CV
Sciences. Capsules were demonstrated by high-performance
liquid chromatography with ultraviolet detection (HPLC-
2 ELMS ET AL.
UV) to contain 22–28 mg of CBD per capsule. Patients were
instructed to take whole capsules, which were assumed to
contain 25 mg of CBD for dosing purposes. Patients were
instructed to take liquid CBD as a speciﬁed number of
sprays from a spray bottle. The liquid product used in this
article was demonstrated by HPLC-UV to contain between
425 and 575 mg of CBD in total per bottle, equating to about
1.5 mg of CBD per spray.
Patients were instructed to take CBD once or twice per
day based on severity of symptoms. The median starting
oral capsular dose was 25 mg per day (range: 25–100). The
median dose of liquid CBD given throughout the study was
9 mg per day (range: 1–16). The mean total starting dose of
CBD (liquid or capsular or both) was 33.18 mg (standard
deviation [SD] =23.34). The mean total dose of CBD pre-
scribed at the 8-week follow-up appointment at the con-
clusion of the study period was 48.64 mg (range: 2–100).
The dose of CBD was adjusted at each 4-week appointment
based on the patient’s presentation and experience. Most
patients received an increase in the dose of CBD because
treatment was provided to maximize PTSD symptom re-
duction, which seemed to be directly correlated with dose.
These doses are much lower than the doses used in the
previous clinical literature for multiple reasons. The ﬁrst is
that lower doses appear to elicit an adequate clinical re-
sponse in our experience. Second, the current retail cost of
CBD would make the use of 600 mg per day cost-
prohibitive. Finally, doses for the liquid spray route of ad-
ministration are typically lower than that of capsules and are
usually measured as single milligrams of CBD per spray,
thus rendering higher doses impractical for patients relying
on liquid CBD.
Informed consent was obtained for each patient at their
intake appointment. Appointments every 4 weeks included
clinical evaluation and documentation of patients’ PTSD
symptomatology through PCL-5 questionnaires. Concurrent
psychiatric medications were held constant or changed ac-
cording to routine clinical practice, whereas CBD was often
intentionally used as a method of decreasing or avoiding the
use of psychiatric medications. CBD was added to care,
dropped from care, or refused as per individual patient and
practitioner preference. The Western Institutional Review
Board approved a retrospective analysis of the charts of
patients with a diagnosis of PTSD who received CBD as
part of their treatment program.
Wholeness Center is a large mental health clinic with a
focus on integrative medicine and psychiatry. Practitioners
from a range of disciplines (psychiatry, naturopathy, acu-
puncture, neurofeedback, yoga, etc.) work together in a
collaborative and cross-disciplinary environment. Based on
existing research and patient experience, CBD had been
widely incorporated into clinical care a few years before
Characteristics of the study sample are presented in
Table 1. The average age of the population in this study was
39.91 (range: 22–69, n=11). The majority (73%, n=8) of
patients were female. On average, patients were concurrently
taking three psychiatric medications, including antidepres-
sants, mood stabilizers, anxiolytics, and stimulants. One pa-
tient used cannabis daily throughout the study. Overall, 73%
(n=8) of patients were concurrently receiving psychotherapy
as part of their overall care. Patients had on average 1.8
comorbid psychiatric conditions in addition to their PTSD
diagnosis, including anxiety, mood, personality, and sleep
Main outcome measures
Changes in PTSD symptoms were assessed by admin-
istering PCL-5 questionnaires before starting CBD and at
4-week intervals thereafter. The PCL-5 is a reliable and valid
test published in 2013 to provide an assessment of PTSD
symptoms that is consistent with changes to the criteria of
PTSD in the DSM-5.
Patients complete a 20-question self-
report form that rates their symptoms on a scale of 0–4, with
total scores ranging from 0 to 80. The PCL-5 is used only to
assess PTSD symptom severity and no particular numeric
score establishes a deﬁnitive diagnosis of PTSD, although
a provisional diagnosis of PTSD may be established based
on (1) individual scoring clusters in relation to the diagnostic
criteria of the DSM-5 or (2) a cumulative score of 33 or
greater. Side effects and tolerability were assessed through
spontaneous patient self-report and were documented in
case records accordingly. Any other spontaneous com-
ments or complaints of patients were also documented in
case records and included in this analysis.
After patient information was de-identiﬁed, the main
outcome measure of total PCL-5 score was tracked and
descriptively analyzed based on mean score and percentage
change from the prior 4-week appointment. The endpoint
for statistical analysis of the study was set at 8 weeks after
initial evaluation. Data beyond this period were not ana-
lyzed because follow-up beyond this period dropped to
<50%. However, anecdotal data were still considered and
qualitatively presented in the Results sub-section.
Table 1. Characteristics of the Patient Population
and Concurrent Treatments Received
Age, mean (SD) 39.91 (17.39)
Male 3 (27)
Female 8 (73)
Total psychiatric medications received,
Relevant medication classes received by patients, n(%)
Anticonvulsant 6 (54.55)
Antidepressant 6 (54.55)
Antipsychotic 2 (18.18)
Anxiolytic/sedative 6 (54.55)
Beta-blocker 4 (36.36)
Number receiving psychotherapy, n(%) 8 (73)
Psychiatric comorbidities, mean (SD) 1.8 (1.54)
SD, standard deviation.
CANNABIDIOL IN THE TREATMENT OF PTSD 3
Of the initial 21 patients who were prescribed CBD and
attended at least one follow-up appointment, 86% (n=18)
remained on CBD and completed PCL-5 questionnaires at 4
weeks of follow-up. This number dropped to 67% (n=14) at
8 weeks of follow-up. This is generally reﬂective of normal
attrition rates experienced in this clinic, and reasons for dis-
continuation of care were largely unknown. Of the 14 patients
who remained in the study at the endpoint of 8 weeks, 11 met
inclusion criteria for data analysis by attending both 4- and
8-week follow-up appointments. Attrition rates by week
are depicted in Table 2.
The baseline mean PCL-5 score for the statistical analysis
sample was 51.82 (SD =9.13). After 4 weeks of treatment,
91% (n=10) of patients from this group reported a decrease
in symptoms of PTSD. PCL-5 scores declined from 51.82 to
40.73 (SD =12.92), a decrease of 21%. One patient did,
however, experience an increase in PCL-5 score from 51 to
63. After 8 weeks of treatment with CBD, 73% (n=8) of
patients reported a further decrease in PTSD symptoms from
their follow-up appointment 4 weeks earlier, and the aver-
age PCL-5 score decreased 9% down to 37.14 (SD =14.38).
At 8 weeks, 27% (n=3) of patients had worsening of PTSD
symptoms from their prior 4-week appointment, with a
mean score increase of 8 (SD =6.08). Despite this increase
from the prior appointment experienced by some patients,
nearly all patients (n=10) reported a PCL-5 score that was
lower than their baseline at the beginning of the study, with
an average decrease of 28%. The results of the study are
depicted graphically in Figure 1.
Four patients from the initial sample continued to receive
CBD for 36 weeks or more. These patients had an initial
mean PCL-5 score of 57.75 (SD =6.20) and all experienced
long-term sustained decreases in PCL-5 scores, with a mean
score at 36 weeks of 29.25 (SD =9.88). An unexpected
ﬁnding revealed through the course of this analysis was a
possible effect of CBD on nightmares. Item number 2 on the
PCL-5 questionnaire assesses symptoms of ‘‘repeated, dis-
turbing dreams of the stressful experience.’’ Of the patients
who responded to item number 2 on the PCL-5 with a se-
verity rating of 3 (‘‘quite a bit’’) or higher, 50% (n=4)
reported a subjective improvement in their nightmares after
starting CBD. Of the total 21 patients in the original sample,
38% (n=8) also reported subjective improvement in the
quality of their sleep. Other reported beneﬁts of CBD in-
cluded decreased anxiety (n=3), improved focus (n=1), and
improved mood (n=1).
CBD was well tolerated by the majority (76%, n=16) of
the total number of patients (n=21). Two patients reported
feeling fatigue after taking CBD. One patient experienced
daytime fogginess and impaired concentration the day after
a night-time CBD dose. Two patients reported gastrointes-
tinal bloating or pain. One of these patients had pre-existing
inﬂammatory bowel syndrome and anorexia. One patient
with a history of gastroesophageal reﬂux reported worsening
Patients taking daily oral CBD over an 8-week period
demonstrated an overall decrease in PTSD symptom se-
verity as measured by continual decreases in mean PCL-5
scores. CBD was well tolerated and no patients discontinued
it due to side effects, although a minority of patients did
report fatigue and gastrointestinal discomfort. It is unclear
whether the fatigue caused by CBD is due to a sedative
effect, and further information should be obtained about the
safety proﬁle of CBD.
Doses of CBD used in this study were generally lower
than those used in prior preclinical and clinical research.
Patients did generally report greater improvement in symp-
toms with higher doses of CBD. Further investigation into
the optimal dosing of CBD for PTSD is warranted. Patients
also received liquid spray and oral capsular forms of CBD,
and it is unknown whether there is a difference in response
between the two routes of administration. CBD is commer-
cially available in many different forms, and further studies
should be done to determine the most effective form of CBD.
A surprising number of patients with signiﬁcant symp-
tomatology related to PTSD nightmares reported subjective
improvement in these symptoms. It is unclear whether this is
due solely to the placebo effect or an effect of CBD based
on a previously unknown mechanism of action. Due to the
current paucity of medications approved for PTSD night-
mares, further investigations should examine whether CBD
Table 2. Number of Patients Who Presented
at the Corresponding Four-Week Interval
Appointment After Their Intake and Completed
Weeks in study
Number of patients
(% of initial sample)
Intake 21 (100)
4 18 (86)
8 14 (67)
12 8 (38)
16 6 (29)
20 7 (33)
24 5 (24)
28 4 (19)
32 4 (19)
36 4 (19)
40 3 (14)
PCL-5, Post-Traumatic Stress Disorder Checklist for the DSM-5.
FIG. 1. Mean PCL-5 score of the sample over the course
of the study depicted as a function of time showing the
observed decrease. PCL-5, Post-Traumatic Stress Disorder
Checklist for the DSM-5.
4 ELMS ET AL.
has a clinical beneﬁt for patients with PTSD-related night-
Although a qualitative examination of the results of this
study appears to show a sustained decrease in PCL-5 score
after extended periods, the early endpoint for statistical
analysis makes it difﬁcult to deﬁnitively determine whether
continued use of CBD results in continued improvement of
symptoms. We have shown that the mean PCL-5 score de-
creased at every 4-week interval for the majority of patients
at the 4- and 8-week follow-ups, but further work should be
done to determine how long this effect continues and whe-
ther there is an eventual reversal and return to baseline.
The results of this study should be interpreted carefully
as this was a retrospective, open-label chart review and, as
such, does not include a placebo or a control group. Con-
current psychiatric medications were frequently added,
removed, and changed through the course of the study. A
precise dosing system for CBD was not established, and
regimens varied between patients. Patients also received
liquid or oral capsular CBD without a deﬁnitive guideline,
and typical doses between the two routes of administra-
tion differed widely. Although the product was derived
from agricultural hemp, it may still contain trace amounts
of delta-9-tetrahydrocannabinol. The sample used in this
study was small in size, consisting of only 11 patients, and
was disproportionately female. Signiﬁcant attrition was
observed and some patients could not be included based on
non-consecutive appointments, further reducing the sample
size and limiting the endpoint of the analysis to 8 weeks
after initial evaluation. The study was conducted at a clinic
with a focus on integrative medicine, and the patient popu-
lation may differ at baseline from the general psychiatric
population. There may also be a selection bias among this
patient population as patients at this clinic often seek to avoid
the use of psychiatric medications. The role of cannabis in
society and patients’ pre-existing beliefs may have played a
role in the way that patients experienced CBD and could
plausibly contribute to an increased placebo effect. Rando-
mized, controlled studies are clearly indicated to fully explore
the beneﬁt of CBD for symptoms of PTSD that was observed
in this chart review.
This retrospective chart review represents the ﬁrst case
series, to our knowledge, examining the effect of CBD on
symptoms of PTSD in humans. The results indicate that oral
CBD, when given in addition to routine outpatient psy-
chiatric care, may have a beneﬁcial effect for patients
CBD is a phytocannabinoid compound found in plants of
the genus Cannabis. It is not responsible for the psychoto-
mimetic effect traditionally associated with cannabis use, as
this is attributed to another phytocannabinoid: delta-9-
tetrahydrocannabinol (delta-9-THC). Different varieties of
cannabis may have differing percentages of CBD and delta-
9-THC. Although CBD can be derived from cannabis plants
that are grown for recreational use, the CBD used in this
study was derived from agricultural hemp, a cannabis plant
that contains <0.3% delta-9-THC. The process of extracting
CBD oil yields not only a product containing almost entirely
CBD but also other cannabinoids in trace amounts, and it is
not completely free of delta-9-THC. CBD remains in a legal
gray area and there have recently been frequent changes to
policy. Although law varies from state to state, CBD re-
mains federally illegal and categorized by the Drug En-
forcement Administration as a Schedule I substance.
No ﬁnancial support of any kind was provided to the
authors or clinic. CV Sciences provided CBD products for
the study. CV Sciences was not involved in the data col-
lection, data interpretation, the preparation of the article, or
the decision to submit for publication. The authors would
like to express their deep appreciation to the staff and cli-
nicians at Wholeness Center for their professionalism.
Author Disclosure Statement
S.S., MD has published four professional books in the
area of Integrative Mental Health. Dr. S.S. is a Principal
Investigator for a Phase III study of MDMA assisted
psychotherapy for severe PTSD and receives compensa-
tion for his clinical work from a nonproﬁt corporation,
the Multidisciplinary Association for Psychedelic Studies.
Dr. S.H., Dr. N.L., and Mr. L.E. report no competing ﬁ-
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Address correspondence to:
Scott Shannon, MD, FAACAP
2620 East Prospect Road, #190
Fort Collins, CO 80525
6 ELMS ET AL.