Case Report

Medical Condition:Psychiatric disorders

Comorbidities

Harm Reduction: Alcohol Use Disorder, Cannabis-induced Psychotic Disorder and a tale of two Hemp Oils, in a Patient diagnosed with a Cluster A & B Personality Disorders in Long Term Behavior Therapy.
Medical Condition
Psychiatric disorders
Symptoms
Cravings and a strong desire to use alcohol, failure to maintain work, continuing to use alcohol despite having interpersonal problems worsen, other activities used for leisure stopped, alcohol use continued despite awareness of prior history of suicidal behavior and legal problems (incarceration secondary to DWI and assault of a police officer), tolerance, cannabis use, abandonment fears, unstable interpersonal relationships, emotional instability, impulsivity, suspiciousness, obsessive compulsivity, problems with attention and concentration, a history of sexual abuse and sexual acting out, pain secondary to breast cancer and a thought disorder.
Psychiatric Disorders
Personality disorder
Abstract
This case highlights the use of harm reduction approaches, motivational interviewing techniques and cannabidiol, in a person, diagnosed with cluster A and B traits - other specified personality disorder 301.89 (F60.89), personal history (past history) of sexual abuse in childhood V15.41 (Z62.810), obsessive-compulsive disorder 300.3 (F42), major depressive disorder 296.22 (F32.1) alcohol related disorder 303.90 (F10.20), Substance induced psychotic disorder with onset during intoxication (F12.259) and attention-deficit disorder predominantly hyperactive/impulsive presentation 314.01 (F90.8) who suffered severe psychosocial stressors and relapsed after over ten years of sobriety on alcohol and cannabis.
Patient information
Gender
Female
Age
35-44
Brief history and target symptomatology
The patient was in behavior therapy once a week for five years. The patient was in A.A. stable and progressing in treatment until a series of external events and her reaction to them destabilized her and she relapsed on alcohol and then cannabis. At the start of treatment she presented with subtle circumstantial speech. In session shaping was used to modify this behavior. Diagnostically, the patient looked like an old school borderline, not psychotic but seemly on the borderline of a thought disorder. The first destabilizing event was being diagnosed with breast cancer during engagement to a man she developed misgivings about. The patient underwent a radical mastectomy and reconstruction surgery got married and within a short time divorced. The divorce in turn triggered psychosocial stressors in relation to financial and emotional instability. During this time the patient was experiencing pain secondary to cancer and was placed on pain medication. The patient was on multiple psychotropic medications: Escitalopram Oxalate, Adderall and Zolpidem. The combination of the stressors, pain and psychotropic medications strengthened a prior maladaptive coping response, the detached protector, unconsciously used as a psychological defense to blunt emotional pain. In addition, the patient relationship hopped into a stormy relationship with a man during her separation prior to divorce. The situation became more unstable as the patient began having relationship problems in her new relationship and subsequent job problems then job loss. This triggered a dramatic period of turmoil in the patient from 2/25/13 to 7/15/13 during which time she was also in an outpatient substance abuse program to reduce the use of pain medication and psychotropic medication, at this time the patient stopped her sobriety of over 10 years, and eventually admitted herself for psychiatric hospitalization. The target symptoms of clinical interest was harm reduction: trying to stop drinking behavior and the use of cannabis in a person who is willful to stop despite some insight that alcohol use is suicidal behavior, as per history of psychiatric, medical and legal problems all alcohol related. Despite all of these symptoms the patient did come to every psychotherapy session, except when she was in an outpatient drug rehabilitation program to reduce pain and psychotropic medications, missing the last two scheduled appointments.
Previous and current conventional therapies
Behavior therapy -Motivational Interviewing techniques, Schema focused therapy, Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, Dialectical Behavior Therapy, Behavior Modification), Pain management, Psychopharmacology.
Clinical response to Cannabis
Working with the patient psychotherapeutically she stopped alcohol use. Stopping alcohol use as per harm reduction was very significant as per suicidal and other self defeating behaviors. She was willful however, about stopping cannabis use. The challenge with the patient’s cannabis use is that she diagnostically had cluster A and B personality disordered presentation and had circumstantial speech, the effects of the cannabis, started to evoke more of a thought disordered presentation but still not psychotic one. Cannabidiol was recommended to the patient as a harm reduction intervention to reduce the chance of a psychosis developing. The patient was willing to try cannabidiol in the form of “drops” placed under the tongue. As per her willfulness I did not get specific with the patient as per dose and timing of dose with cannabidiol. I simply told the patient “this is good for you it will help you and you can’t kill yourself with it, the only thing I ask is that you use the cannabidiol every time you use cannabis and use your own wise mind to find a balance that works for you”. Within two weeks of pairing the cannabidiol with smoked cannabis she reported, a reduction in agitation, paranoia, and stopped acting out sexually in bars. In week three the patient reported a reduction in anxiety, and started to report a tremendous surge in reflective functioning, awareness of awareness. This change in reflective functioning was very beneficial to the patient, for example schema activation, became easier to spot and the patient was able to utilize these connections to reduce her use of pain medications (working with her pain management doctor), and make less self defeating decisions feeling more present in the moment then being in ones head (fused with thought), and felt more confident handling interpersonal situations. In week four of cannabidiol paired with cannabis the patient contemplates looking for work and is working on her resume. She continues to benefit from increased reflective functioning and is improving with emotional regulation, interpersonal communication and awareness of her own thought process (schema activation). Week five the is patient in awe of her insights into her thought process, reporting a reduction in impulsivity secondary to reflective functioning, her ability to attend to the external environment improved, she felt calmer and more organized in her thinking. Week six the patient reports that she is able to observe her own splitting or all or nothing thinking more clearly and how fast she turns, shifting from one psychological mode to another (vulnerable child, angry child, and undisciplined child). Week 7 a change is noted in session. The gains made in prior sessions appear to wan and the patient presented with an increase in thought disorder. Assessment revealed a tale of two very different hemp oils and speaks to the confusion surrounding this term. The patient read on the oral drop label of the cannabidiol the term hemp oil and secondary to her obsessive nature went on line and discovered the Simpson treatment and followed his method for hemp oil from cannabis. This hemp oil has far more potency, as per 9-tetrahyrocannabinol, in the liquid form. She reported that she could no longer afford cannabidiol and stopped its use. The patient was willful to stop using the Simpson treatment, despite attempts to educate and confront her willfulness. Week 8 the patient is using only the Simpson treatment. Despite her appearing high the patient still had the benefits of years of our treatment accessible to her and the increased reflective functioning, she reported and we worked on her profound insight, her underlying thought disorder. The patient disclosed that she was living in shame of stigma of being diagnosed with a thought disorder and a fear of medications that a prior psychiatrist had wanted to put her on. She revealed that “I used to say to myself this was my prior LSD use but now I can see its not and I’m aware and I’m sharing about it”. Week 9 the patient reveals that the disclosure of her psychotic process was very helpful although difficult to do and feels less shame. While these insights were extremely helpful to the patient’s overall future mental health her current functioning was more impaired secondary to the Simpson treatment. The patient was willful about stopping her use of the Simpson treatment despite increased relationship and work challenges. She reported that it’s as if “your brain ran at half speed and then you feel that you have your brains back”. Week 10 turns out to be our last session. Two more sessions were scheduled but the patient failed to show up. During our last session, the patient was less organized in her thinking, showing signs of persecutory delusions, and is less willful about stopping the Simpson treatment and more willing to restart cannabidiol as a mono therapy, seeing a psychiatrist or going in patient. I never see the patient again. Three weeks later I get a call from a psychiatric nurse at a facility hour’s away upstate. The nurse asked for clinical information about the patient as per our treatment, at the end of our conversation the nurse said, “the patient said it was very important, to tell you that “you have been a great help to her, she believes that between the psychotherapy and the CBD (cannabidiol), what ever that is, she now realizes that she does have a thought disorder and is willing to be assessed by our psychiatrists and that she would take an anti psychotic if recommended”. The psychiatric nurse was very intrigued by the patient’s presentation and the use of cannabidiol. “Up here (a rural part of the state) we don’t hear as much about new treatments what is this stuff, CBD, anyway?”
Additional Comments
What makes this case unique is the growth the person continued to experience even in the face of a developing psychosis. The relapse occurred within the on going context of behavior therapy and even as cognitive abilities became more disorganized other parts of her thinking showed more clarity and insight into her own cognitive functions when cannabidiol was introduced. Harm reduction had several goals that were accomplished. The first was continuing to treat the patient despite her willfulness to work with a psychiatrist, go inpatient, etc. Based on continuity of treatment, the patient became willing to stop using alcohol, which was suicidal behavior as per her history. Treating a willful patient who will not stop using cannabis and who diagnostically is in a population at risk for psychosis was the aim of the cannabidiol intervention. What worked was to tap into her willingness via motivational interviewing techniques that helped her to see that cannabis, despite the risk of psychosis based on diagnosis, was actually less harmful than alcohol as per her own history of assaulting a police officer, multiple DWI’s, sexual acting out and other self defeating behaviors. The next intervention as per cultivating her willingness was her agreeing to add cannabidiol when she was using cannabis. Clinically the goal of adding the cannabidiol was to reduce the probability of a psychosis. I was surprised to find that not only was a psychosis temporally avoided, but in addition the patient reported improvements in cognitive functioning, as per her attention and concentration, and increased reflective functioning which resulted in increased abilities to identify automatic thoughts and schema activation and use this knowledge in a goal directed manner. The patients self report of adding the cannabidiol to her cannabis use was dramatic in her positive descriptions of self states, seeing her role in interpersonal interactions more clearly, her thinking was more organized and she reported a reduction in anxiety. These positive experiences in the context of a strong therapeutic relationship combined with the cannabidiol increased insight and willingness to finally accept, while working through shame and feelings of defectiveness, that she did have a psychotic disorder and she admitted herself for psychiatric hospitalization and hopefully a change in her stance toward a different diagnosis and different psychotropic medication, just as was recommended to her so long ago. This case highlights the fact that the cannabis did not cause a healthy person to suddenly develop a psychosis rather the psychotic predisposition was already present in the patient.
I was completely thrown at first by the patient’s different presentation at week 7 when unknown to me the patient started using the Simpson treatment. The fact that cannabidiol can be derived from hemp and can be called hemp oil is a look alike problem with hemp oil that contains 9-tetrahyrocannabinol. Differentiation of these terms is crucial for a public that maybe naïve to the differences. The other related challenge, I deduced, is that the patient thought that the Simpson treatment was the same as smoking cannabis, obviously it is not. The dosing of the liquid Simpson treatment was like rocket fuel compared to bottle rocket used on the fourth of July. The patient with her predisposition for a thought disorder was a poor candidate for such a treatment. This is important in the medical uses of cannabis for non psychiatric conditions that may use high doses of liquid 9-tetrahyrocannabinol and strengthens my recommendation that a patient’s psychological health needs to be assessed prior to such treatments.
Cannabis
Usual method of Cannabis administration
Ingested
Cannabis strain (if known)
Oral liquid for sublingual adsorption called Dew Drops. Patient, secondary to contextual treatment issues of willfulness was encouraged to find here own level of use in the context of cannabis use for the purposes of harm reduction.Secondary to willfulness the patient’s ability to follow guidelines of use was much challenged. Motivational interviewing approaches were beneficial in stopping alcohol use and the start of cannabidiol. The patient was encouraged to find her own level of cannabidiol use. I believe that therapeutic communications that encouraged autonomy and belief in her as competent was beneficial in helping the patient gain influence over her own behavior, as clearly highlighted by the case. I stuck with the patient, didn’t judge her and as such taught her how to nurture and guide herself resulting in her not killing herself. Additionally over a difficult but short time she shifted into willingness, disclosing her shameful secret of having a thought disorder, admitted herself to a hospital for inpatient psychiatric care and was now open to different types of medical interventions anti psychotic medications.Secondary to willfulness the patient’s ability to follow guidelines of use was much challenged. Motivational interviewing approaches were beneficial in stopping alcohol use and the start of cannabidiol. The patient was encouraged to find her own level of cannabidiol use. I believe that therapeutic communications that encouraged autonomy and belief in her as competent was beneficial in helping the patient gain influence over her own behavior, as clearly highlighted by the case. I stuck with the patient, didn’t judge her and as such taught her how to nurture and guide herself resulting in her not killing herself. Additionally over a difficult but short time she shifted into willingness, disclosing her shameful secret of having a thought disorder, admitted herself to a hospital for inpatient psychiatric care and was now open to different types of medical interventions anti psychotic medications.
Frequency of Usage: Time Per Day
6 or more
Frequency of Usage: Days per Week
7

Case Report

Medical Condition:Adverse effects

Comorbidities

Congenital nystagmus improved by marijuana
Medical Condition
Adverse effects
Symptoms
Blurred vision related to nystagmus
Abstract
19-year-old high school graduate, works 30 hours a week as a cook in a cafeteria, wears corrective glasses for myopia, has congenital horizontal nystagmus in both eyes. Marijuana slows or relieves eye movements, improving vision and ability to read.
Patient information
Gender
Male
Age
18-24
Brief history and target symptomatology
Patient presented for first marijuana recommendation because of recent trauma to right wrist causing persistent constant pain. He has been using nonmedicinal marijuana since age 15 to relieve eye discomfort due to nystagmus. On examination, horizontal nystagmus OD>OS is confirmed, at a rate of 1-2 movements per second.
Previous and current conventional therapies
None.
Clinical response to Cannabis
Decreased eye discomfort and improved vision.
Additional Comments
References:
Very few peer reviewed. "Toxicology observation: nystagmus after marijuana use." J Forensic Leg Med. 2013 May;20(4):345-6. doi: 10.1016/j.jflm.2012.07.014. Epub 2012 Sep 1
Anecdotal: "Nystagmus Discussion Board: Treatments and Surgeries: Alternative Medicine: Medical Marijuana."

1.Nystagmus Discussion Board: Treatments and Surgeries: Alternative Medicine: Medical Marijuana. (Anecdotes.)
Cannabis
Usual method of Cannabis administration
Smoked
Frequency of Usage: Time Per Day
1
Frequency of Usage: Days per Week
7
Reported by

Case Report

Medical Condition:Sleeping disorders

Comorbidities

Marijuana helps narcolepsy
Medical Condition
Neurodegenerative disorders
Symptoms
Short episodes of daytime sleep attacks and poor sleep
Neurodegenerative Disorders
Unspecified
Abstract
A 32-year-old male, furniture mover of 13 years, found relief of daytime sleep attacks and experienced more restful sleep with marijuana.
Patient information
Gender
Male
Age
25-34
Brief history and target symptomatology
Furniture mover for 13 years uses marijuana for relief of chronic back pain, short sleep attacks in the daytime and unrestful sleep.
Previous and current conventional therapies
OTC medication for back pain in the past. Diagnosed with narcolepsy but refused conventional treatment in favor of marijuana.
Clinical response to Cannabis
Alertness throughout the day, ability to work steadily, restful sleep.
Additional Comments
Diagnosed with idiopathic narcolepsy, no history of TBI or other neurological disorders. Patient attributes effect of marijuana on REM sleep for the relief of his symptoms.
Reference: National Sleep Foundation. "For people with narcolepsy, sleep begins almost immediately with REM sleep and fragments of REM occur involuntarily throughout the waking hours. When you consider that during REM sleep our muscles are paralyzed and dreaming occurs, it is not surprising that narcolepsy is associated with paralysis, hallucinations, and other dream-like and dramatically debilitating symptoms. "
Cannabis
Usual method of Cannabis administration
Smoked
Frequency of Usage: Time Per Day
2
Frequency of Usage: Days per Week
7

Case Report

Medical Condition:Adverse effects

Comorbidities

Achalasia, status post myotomy
Medical Condition
Adverse effects
Symptoms
Postprandial cramps, frequent nausea, general dyspepsia
Abstract
About 2 years post lower esophageal sphincterotomy for achalasia, this 35-year-old female suffered from general dyspepsia associated with difficulty falling asleep. She used both inhaled and ingested marijuana daily in small amounts which relieved her symptoms without the need of additional medications.
Patient information
Gender
Female
Age
35-44
Brief history and target symptomatology
35-year-old female social worker, married, two teenagers at home, employed full-time. Underwent Heller myotomy for achalasia. Esophagram six weeks postop showed good distensibility of the esophagus, and quick emptying. Postprandial cramps and frequent nausea started in the postoperative period and continue 15 months postop.
Previous and current conventional therapies
The patient was treated with Protonix and Pepcid following Heller myotomy. She no longer takes those medicines and uses cannabis instead.
Clinical response to Cannabis
Relief of GI discomfort and of associated sleep disorder.
Additional Comments
According to NORML ( Main » Library » Health Reports » Recent Research on Medical Marijuana » Gastrointestinal Disorders): "Preclinical studies demonstrate that activation of the CB1 and CB2 cannabinoid receptors exert biological functions on the gastrointestinal tract.[6] Effects of their activation in animals include suppression of gastrointestinal motility,[7] inhibition of intestinal secretion,[8] reduced acid reflux,[9] and protection from inflammation,[10] as well as the promotion of epithelial wound healing in human tissue.[
Cannabis
Usual method of Cannabis administration
Ingested
Frequency of Usage: Time Per Day
1
Frequency of Usage: Days per Week
5

Case Report

Medical Condition:Psychiatric disorders

Comorbidities

The use of Cannnabidiol (CBD) and Meditation to reduce Binge Drinking, Anxiety and to improve Emotional Regulation in Long Term Behavior Therapy
Medical Condition
Psychiatric disorders
Symptoms
309.81 (Posttraumatic Stress Disorder), 301.83 (Cluster B Personality Disorder, Borderline Personality Disorder), 304.20 (Stimulant-Related Disorder, Cocaine, in sustained remission, 305.1 (Tobacco-Related Disorder, Moderate in sustained remission, 303.90 (Alcohol-Related Disorder, Severe, in early remission, 9 months), 300.4 (Persistent Depressive Disorder) V61.03 (Disruption of family by divorce).
Psychiatric Disorders
ADD / ADHD
Abstract
This case study focuses on the use of CBD within long term behavior therapy. CBD was used for harm reduction: reduce binge drinking and the associated emotional triggers of the addiction, anxiety and problems with emotional regulation. A very beneficial treatment sequence was revealed in the therapy, the initial use of CBD then the addition of meditation to form a treatment package which increased mindfulness and reflective functioning. This case shows that psycho education is an integral process of CBD initiation.
Patient information
Gender
Male
Age
45-54
Brief history and target symptomatology
The patient presented with distress in multiple areas of functioning, 8/16/2006. He was newly divorced, using alcohol, cocaine and tobacco and depressed and anxious. His patterns of use were masked by his working as an executive in a field related to the entertainment industry where substance use and abuse are common. Behavior therapy was conducted once per week for 45 minutes. Cocaine use was in early remission by 2007. A slight reduction in daily alcohol consumption occurred but alcohol binges, mood swings and interpersonal challenges continued for the patient in 2008. In 2008, the patient was willing to see a psychiatrist and was placed on Sertaline HCI (anti depressant) standing dose 200mg and Acamprosate (curb the urge to drink), which was poorly tolerated and discontinued secondary to side effects. Slight reduction in daily drinking continued no change was noted in binge drinking. Key events of 2009, the patient remarries. The patient was willing to try controlled drinking, trying to stop at two drinks in social situations and at home. Binge drinking continues. Therapeutic issues during 2010, birth of son. The patient is now able to use controlled drinking and remains willful about stopping alcohol altogether. An increase in overall emotional regulation is observed and the patient stops smoking tobacco. He has a binge on a work trip and gets into a fight with a hotel security guard for being intoxicated. The police are called and when the patient gets belligerent he is hit repeatedly by the police. All charges were later dropped. Events in therapy during 2011, the patient is willing to try exercise as an alternate stress reducer, continues to use controlled drinking on a daily basis and still has emotionally triggered binges which last 2-3 days, suicidal ideation with no plan and had painful withdrawal symptoms but the patient was willful about going inpatient. In 2012, the patient states in passing that he is longer working with a psychiatrist, his general practitioner continues the Sertaline HCI. However, he is now willing to stop controlled drinking and on a daily basis, abstain from alcohol. Binges, however, still occur based on emotional triggers. He had one binge that lasted four days and included a fight in a bar resulting in chipped teeth, facial abrasions and contusions, a black eye and severe withdrawal symptoms and suicidal ideation with no plan. The patient refused medical care all but for his teeth. It was at this point in treatment to target harm reduction; reduce binge drinking, anxiety and increase emotional regulation, the emotional triggers of binges that a trial of CBD was initiated.

Target symptoms: Harm reduction, the cessation of binge drinking, anxiety reduction and emotional regulation.
Previous and current conventional therapies
Long term behavior therapy including: Cognitive behavioral therapy, Acceptance and Commitment therapy, Schema Focused therapy, Dialectical behavior therapy, Functional Analytic psychotherapy, Relaxation techniques, and A-B-C functional analysis of drinking patterns. Pharmacological treatment comprised of Sertraline HCI, 200mg, Acamprosate, which was discontinued secondary to side effects.
Clinical response to Cannabis
Cannabidiol (CBD) was first introduced as a treatment option. The patient started oral drops on 1/31/13 to assess tolerability and efficacy. The CBD was well tolerated but no clinical efficacy was noted. On 2/21/13 the patient started 1 CBD pill (range 20-25mg) in the morning. The patient reported a slight reduction of anxiety, an increase in being more present in-the-moment (mindfulness) and a reduction in the urge to drink. Continued progress was made until a binge with suicidal ideation occurred on 4/3/13. On 4/24/13 the dose of CBD was changed from a standing A.M. dose to an as needed dose, based on emotional cues such as anxiety and the urge to drink. In the next few weeks the patient reported improved mood and no binges occured. Between 5/8/13 and 5/22/13 the patient runs out of CBD secondary to cost but returns to its use on an as needed basis. The patient has been continuing to exercise but aggravated an old injury in his shoulder secondary to an old bar fight. The patient compensates by following a prior recommendation, and begins a meditation class on 6/26/13. On 7/30/13 the patient reports “I guess I’m getting better”. The meditation class ends on 8/13/13 and the patient commits to maintaining the practice of meditation. Treatment continues with the patient until again the cost of the treatment of CBD is prohibitive. However, the gains he made from the window of time where CBD was started and then meditation added continue, he is more emotionally regulated, and has stopped the self defeating pattern of binge drinking. He is off alcohol completely and is now in early remission for the past 9 months.
Additional Comments
Psycho-education was an important part of the CBD trail. Psycho-education started off with introducing CBD as per the efficacy, side effect profile, methods of administration, the difference between THC and CBD, specifically that CBD will not produce euphoria, and providing a treatment rationale which allowed the patient to process his attachment to his doctor and his prior attachment to substances. For instance, the patient said, “Wow with my history I can’t believe you are recommending part of the Cannabis plant to me”, “the psychiatrist before this one gave me a benzodiazepine for sleep and I started abusing it”. The patient was provided with a study using CBD to reduce anxiety and instructed to look at the web site the CBD Project and to ask questions. The patient asked if he could share the article with his wife. He came back to the next session stating that he and his wife had read the study and looked at the CBD Project and felt in agreement that the profile of CBD looked much less harmful then Alcohol and anything else he had ever used including medications for psychopharmacology. Psycho-education was integral in shifting from a standing dose to use as needed and increased even more trust in the doctor patient relationship. The patient’s own negative attachment to himself (ambivalent/anxious) as per his impulse control and prior attachment to substances (preoccupied/attached) and to a concurrent style of attachment for safety (fearful/withdrawn) were all addressed therapeutically prior to starting CBD mono therapy.

CBD as a mono therapy then adding mediation/mindfulness training appeared to be a beneficial sequence of interventions and warrant future study as a treatment package. Behavior therapy, as practiced in this case study, has aspects of mindfulness in the treatment (Acceptance and Commitment therapy and Dialectical behavior therapy) and observable present states in the patient were shaped, however, the psychotherapy was not a meditation class. The CBD treatment may have acted as a precursor for meditation by increasing being present-in-the moment and reflective functioning, awareness of awareness, prior to meditation instruction. Thus, this patient benefited greatly by increasing the benefits of CBD with a skill set, meditation, that appeared to deepen the patient not fusing with thoughts and increased reflective functioning in a synergistic manner. While the patient could not afford to continue with the CBD treatment, he has maintained being more present in-the-moment and the reflective functioning and is continuing the practice of meditation. The patient and I agreed that as his economic situation improves he will go back on CBD.
Cannabis
Usual method of Cannabis administration
Ingested
Cannabis strain (if known)
Available in New York: Dew Drops, Hemp Oil Scripts
Frequency of Usage: Time Per Day
1
Frequency of Usage: Days per Week
7

Case Report

Medical Condition:Psychiatric disorders

Comorbidities

The use of Cannnabidiol (CBD) to Reduce Insomnia and the Urge To Use Alcohol in a Geriatric person in on going Behavior Therapy.
Medical Condition
Adverse effects
Symptoms
300.02 (Generalized Anxiety Disorder), 296.32 (Major Depressive Disorder Recurrent Moderate), 303.90 (Alcohol-Related Disorder Moderate), 301.89 (Other Specified Personality Disorder Mixed Personality Features, Dependent, Schizoid).
Abstract
This case highlights a trail of CBD in an ongoing behavior therapy. CBD was used to: break a cycle of insomnia, secondary to a major depressive episode and reduce alcohol consumption as per an addiction.
Patient information
Gender
Female
Age
65 or Above
Brief history and target symptomatology
Patient sought treatment (cognitive behavioral therapy) after the sudden loss of partner after 30 years of co-habituating / marriage. This was a traumatic event and came not to long after the trauma of 911 in New York City. She presented as anxious and depressed and as treatment progressed disclosed a moderate alcohol addiction. The patient was willing to attend sessions and willful as per reduction of substance abuse. The patient has had difficulty with medical doctors as per trust based on the medical treatment of her significant other. An increase in symptoms of anxiety and depression occurred after a diagnosis of a urinary tract issue warranted a surgical consultation. Target symptoms for CBD: insomnia and alcohol.
Previous and current conventional therapies
Cognitive behavioral therapy, functional analysis of drinking, relaxation techniques, cognitive restructuring, and schema focused therapy. The patient started Escitalopram Oxalate on 3/25/13 and discontinued the anti depressant secondary to the side effect of dizziness on 4/1/13.
Clinical response to Cannabis
To assess tolerability and using the concept of ‘start low and go slow’ for geriatrics, the patient was recommend on 5/2/13, CBD drops, once in the morning, then after one week, morning and evening doses. The CBD was tolerated without side effects. The patient however reported no change in insomnia or drinking. To break the cycle of insomnia Diphenydramine was recommended on 5/13/13. The patient stopped the evening dose of CBD and tried Diphenydramine, reporting that 25mg of Diphenydramine was helpful but not enough to break the cycle of insomnia. The next recommendation 5/20/13 was to keep the morning dose of CBD and in the evening 45 minutes prior to going to bed to add CBD drops with 1 25mg of Diphenydramine. By 6/10/13 the combined treatment broke the cycle of insomnia. The patient reported an increase in better quality of sleep, feeling more restoration post waking and a decrease in depression. Based on the efficacy of this intervention the patient was willing to try 1 CBD pill in the A.M. instead of CBD drops to reduce alcohol use. Morning doses did not produce a therapeutic response and like the drops, the pill form was well tolerated by the patient. Based on a reduction in depression secondary to better sleep the patient was willing to try 1 CBD pill 45 minutes before she started to drink, which started at 5pm and continue till 11pm. She was very ambivalent about giving up alcohol, refused Alcoholics Anonymous and was still willing to try CBD. By 6/24/13 the patient reported a reduction in the urge to have the first drink. On 7/1/13, the patient was encouraged to try to push back the first drink. The patient reported on 7/15/13 that she was able to cut her drinking by one drink.
Additional Comments
The treatment is ongoing. The patient still is very ambivalent about stopping drinking all together. This is exacerbated by the anxiety secondary to the prospect of surgery. However based on the CBD treatment she is surprised that she is able to reduce the urge at all and is contemplating the concept of controlled drinking. The successful cessation of insomnia was a major gain for the patient, improving her mood and her ability to think more clearly about her decision making as per surgical intervention. Standing dose of CBD is: drops in the morning, 45 minutes before her usual drinking time 1 CBD pill and before bed CBD drops and 1 tab 25 mg of Diphenydramine 45 minutes before bed. The biggest challenge to continuing CBD treatment is the expense of the treatment.
CBD was first used in the form of drops and then combined with a pill. Trying to control the use of CBD in the form of a dropper without milligram markings and as the drops were used less would come up in the dropper receptacle from the bottle rendered drops under the tongue difficult to quantify. The patient was encouraged to use 2-3 drops. Due to the current lack availability of CBD, as per state regulations, CDB products were bought online via Dixie Botanicals.
Due to age of the patient and to assess tolerability, drops were introduced first in the morning then morning and night. Sleep was dramatically improved by the combination of CBD drops and Diphenydramine 1 tab 25mg. Alcohol use was reduced by the use of 1 CBD pill 45 minutes prior to drinking pattern started which resulted in a reduction in the urge to drink.
Cannabis
Usual method of Cannabis administration
Ingested
Cannabis strain (if known)
Mono therapy with CBD
Frequency of Usage: Time Per Day
3
Frequency of Usage: Days per Week
7

Case Report

Medical Condition:Psychiatric disorders

Comorbidities

Mixed mood disorder
Medical Condition
Psychiatric disorders
Symptoms
Generalized anxiety, panic attacks, seasonal depression, suicidal thinking, insomnia
Psychiatric Disorders
ADD / ADHD
Abstract
52 y/o male with mixed mood disorder on muliple medications with incomplete improvement, responded well to CBD rich strains of cannbis.
Patient information
Gender
Male
Age
45-54
Brief history and target symptomatology
52 year old male with greater than 30 year history of mood disorder. Past medications included multiple SSRIs, SNRIs, mood stabilizers, benzodiazepines and hypnotics. Cannabis had been quite effective at reducing need for antidepressants for 5 years, however anxiety, panic and insomnia had remained intermittently problematic, and medication side effects were significant. Switched to high cbd strain (Cannatonic) as a bedtime unheated dose with near complete resolution of insomnia and generalized anxiety. Using L-theanine during the day for occasional panick attacks.
Previous and current conventional therapies
Numerous SSRIs, SNRIs, benzodiazepines and zolpidem, talk therapy, numerous traditional herbs, meditation and exercise.
Clinical response to Cannabis
Used as an evening unheated oral preparation, response has been remarkable and improving. CBD dose is estimated to be about 100mg.
Additional Comments
Patient has resumed aerobic exercise and is working to restore previous social activities.
Cannabis
Usual method of Cannabis administration
Ingested
Cannabis strain (if known)
Cannatonic, AC/DC
Frequency of Usage: Time Per Day
1
Frequency of Usage: Days per Week
7

Case Report

Medical Condition:Infections

Comorbidities

Chronic recurring uveitis / iritis responds to cannabis
Medical Condition
Autoimmune disorders
Symptoms
Pressure, pain in both eyes
Autoimmune Disorders
Alopecia
Abstract
60 y.o. woman with 37 year history of iritis/uveitis. Inflammation and dull aching eye pain was managed with oral prednisone followed by continuous use of steroid eye drops until two years ago when the treating ophthalmologist recommended a trial of cannabis which she found eliminated her need for all oral steroids and nearly all topical steroids for the past 2 1/2 years.
Patient information
Gender
Female
Age
45-54
Brief history and target symptomatology
Onset of iritis / uveitis at age 23, associated with mildly elevated antinuclear antibody, but no evidence of other autoimmune or neurodegenerative disease. Both of the irises became "sticky" and asymmetrical but "cooled off" with oral prednisone over the first year. The condition never completely resolved as recurrences began in her late twenties and have continued for thirty years.
Previous and current conventional therapies
For 37 years the patient has frequently used a Medrol Dosepak or prolonged and greater doses of oral steroids and steroid eye drops to reduce the pain and sense of pressure in the eyes. In the past two years she reports using Pred Forte 1% for only a couple days at the hint of eye pain.
Clinical response to Cannabis
Cannabis has been effective at diminishing iritis and uveitis recurrences almost entirely since 2009. Preferred method of administration is ingesting a cannabis infused brownie in the evening, along with infrequent cannabis smoke and/or vapor.
Additional Comments
IOPs have remained in normal range. ANA is reportedly normal. No signs of autoimmune or neurodegenerative disease have occurred.
Cannabis
Usual method of Cannabis administration
Ingested
Frequency of Usage: Time Per Day
1
Frequency of Usage: Days per Week
7

Case Report

Medical Condition:Adverse effects

Comorbidities

Cannabis Overdose
Medical Condition
Adverse effects
Symptoms
Dizziness, Loss of muscle control, Inability to move
Abstract
After smoking an unknown (organic) sample of high-THC cannabis, patient became dizzy and anxious. Symptoms rapidly progressed to complete inability to use voluntary muscles for a period of approximately 30 minutes. All symptoms resolved after several hours of sleep.
Patient information
Gender
Female
Age
55-64
Brief history and target symptomatology
Patient had ingested one margarita approximately one hour prior to smoking a single inhalation of high-THC cannabis. 15 minutes after inhaling, dizziness and anxiety symptoms occurred. 10 minutes later all ability to move voluntary muscles was lost with no effect on breathing or involuntary muscle control. No loss of continence. Speaking was not possible but patient was able to 'grunt'. Catalepsy without rigidity lasted for approximately 30 minutes, but dizziness persisted. Patient was assisted to bed and after several hours of sleep was once again normal. No residual symptoms persisted.
Previous and current conventional therapies
Patient is a many-year experienced cannabis smoker, rarely ingests it due to fear of overdose. Rarely drinks alcohol but is not overly sensitive to alcohol. Taking no other medications - either prescription or OTC.
Clinical response to Cannabis
Loss of muscle control without loss of consciousness.
Additional Comments
Although patient was anxious about the reaction, she does continue to use cannabis. She is careful about the source and the content prior to inhaling or ingesting.
Cannabis
Usual method of Cannabis administration
Smoked
Cannabis strain (if known)
Unknown
Frequency of Usage: Time Per Day
1
Frequency of Usage: Days per Week
7
Reported by
Contributing Physician (optional)
Stacey Kerr MD