Medical ConditionPsychiatric disorders
The use of Cannnabidiol (CBD) and Meditation to reduce Binge Drinking, Anxiety and to improve Emotional Regulation in Long Term Behavior Therapy
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).
ADD / ADHD
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.
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.
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.
Usual method of Cannabis administration
Cannabis strain (if known)
Available in New York: Dew Drops, Hemp Oil Scripts
Frequency of Usage: Time Per Day
Frequency of Usage: Days per Week