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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 ConditionPsychiatric disorders
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.
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.
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?”
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.
Usual method of Cannabis administration
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
Jason Staal, Psy.D.