Tales From the Clinic: Cannabis’ Impact on a Case of PTSD

Kim is a 68-year-old white woman referred to a psychotherapy clinic specializing in treating trauma-related mental health conditions. Kim had no experience with psychotherapy and had only reluctantly decided to seek help. At intake, Kim reported that it had been 13 months since her husband of 43 years committed suicide by hanging. Kim had found his already decomposing body in their basement.

History and Initial Treatment
Kim said she was repeatedly reliving that moment of finding her husband and was unable to stop these memories from intruding into her daily life. She reported difficulty sleeping, with overwhelming nightmares when she was able to get any
significant sleep. Kim had multiple flashbacks of the event throughout a typical day, and the intrusive thoughts were accompanied by noted hypervigilance, increased startle reflex, and feelings of both guilt and hopelessness. Kim reported a lack of motivation and withdrawal from her friends and family. She felt irritable and
endorsed passive suicidal ideation. Based on the initial intake, Kim was diagnosed with post-traumatic stress disorder (PTSD). Her symptoms were severe, and she was asked to sign a contract for safety, to ward off imminent suicidality concerns.

Kim had no psychiatric history before the event, but given the severity of her symptoms and passive suicidality, she was referred to a psychiatrist for immediate assessment. The psychiatrist prescribed 50 mg sertraline, with a slow titration schedule from 25 to 50 mg. Kim reported having difficulty tolerating the sertraline due to stomach upset and “feeling really weird, like I’m out of my body.” Against the advice of both her psychiatrist and therapist, Kim ceased taking sertraline cold turkey and immediately reported “feeling better.”

Nonetheless, her depression continued to increase with time, as did concern over her continued suicidality. She reported “feeling desperate” and said that she had started
drinking alcohol more often at night. During her weekly therapy sessions, which were primarily focused on symptom improvement, she reported that her mood was too fragile to feel motivated to complete (reasonably small) assigned behavioral goals. At this point, I suggested cannabis as a potential direction for treatment.1-4

Cannabis Use for PTSD
Kim used cannabis when she was younger but had not taken any form of cannabinoid for more than 30 years. After a discussion about how her state-run medical cannabis program functioned, Kim agreed to try medical cannabis. However, at her next session, she reported that she had procured “some marijuana from her friend’s son”
who had received it illicitly. Kim was told that her state’s program would be able to provide safer cannabinoid-based medicine, as it is tested for purity and contamination. Kim’s primary care physician was unable to sign a recommendation as the provider’s health system strictly prohibited it. Thus, I strongly encouraged Kim to call a state-approved doctor who is certified to recommend medical cannabis. Kim was assisted with securing an appointment with a certified physician at the only functional cannabis dispensary in the northern part of the state, and in obtaining a legal medical cannabis card. At the appointment, Kim obtained both flower- and
vape cartridge-based cannabis derived from a strain that has shown positive results (according to the manufacturer) in people with sleeplessness, hypervigilance, and depression.

Kim began taking both formulations and reported that she was immediately sleeping better and felt less agitated. She noticed that she felt “less angry around others”
and was able to return to playing golf—one of her favorite pastimes—with her friends. Over time, Kim’s quality of life began to improve with the medicinal use of
cannabinoids. Her feelings of hypervigilance eased, she started feeling motivated to spend more time with her friends, and her mood significantly improved. Kim also
reported that she was experiencing fewer nightmares, and flashbacks of the event were reduced considerably. Kim was stable and, eventually, became motivated enough for us to begin working on her traumatic experience. We were able to look at both her cognition and behaviors, to reframe and rework her thoughts concerning the event, and remodel her behaviors in the absence of prior anxiety.

Effects of Cannabis Cessation
Kim made significant progress until issues arose with supply at the providing dispensary. The primary dispensary suffered shortfalls in production, negatively affecting their ability to meet patient demands. The particular variety of cannabis flower (and extracted oil) that Kim had used was no longer available, and other similar varieties also were unavailable. As a result, Kim was no longer able to procure the cannabis that had successfully and significantly reduced her symptoms of PTSD. Slowly, the same difficulties with sleeping and arousal states eventually returned at the same level of severity, increasing the frequency of flashbacks of the event, and finally resulting in a pronounced dysthymia. There was an apparent correlation between the reduction of Kim’s cannabis use (due to the unavailability of a specific variety) and the increase in her PTSD-derived symptoms.

At this point, Kim’s primary care physician prescribed zolpidem, which she eventually stopped taking because of significant side effects. Psychotherapy had to revert to
more basic therapeutic work centered around ensuring safety and support.

Resumption of Cannabis Use and Follow-Up
After a few months, the dispensary began stocking the same variety of cannabis that Kim had previously used. She began to use cannabis daily in low dosages with similar improvement in symptoms. Kim reported that cannabis administration assisted in
improving the quality of her sleep, reduced the severity and frequency of her flashbacks, improved her motivation, and elevated her mood. She began “re-engaging
in the world” and working on her cognitive understanding of the traumatic event that brought her to therapy originally. It has been 3 years now since her husband’s death, and Kim is finally starting to feel like herself again. Her quality of life has returned.

Commentary
As a clinician, it is my job to advocate for my clients. Kim is a typical example of one of the fastest growing patient demographics in the United States (ie, the older population). Kim’s lack of understanding about the differences between the illicit “marijuana” market and the legal and regulated cannabis market led her to
make inadvertently risky decisions concerning her own medication. Additionally, issues regarding insufficient state supplies of safe and standardized cannabis are of
vital concern to anyone using cannabis medicinally.5,6

Notably, I had called a local dispensary asking for a detailed account of what products were in stock.

Regrettably, the staff refused to provide information to me until I informed them that
I, too, was a state medical cannabis cardholder. After verifying my personal information, the dispensary staff provided information on that day’s available cannabis varieties (aka “strains”). This enabled me to identify the variety that may have the most significant effect on Kim’s symptoms of sleeplessness, hypervigilance, and depression. Thus, health care professionals without a medical cannabis card may have difficulties when calling dispensaries on their patient’s behalf to determine which cannabis strains are in stock and in order to recommend a strain that may best treat their symptoms.

As has been demonstrated in similar preclinical trials, Kim’s use of cannabis seemed to help reduce both her startle reflex and flashbacks.2,7-9 In this particular case, Kim’s use of cannabis provided significantly less adverse reactions than were reported from zolpidem use. In light of these findings—as a clinician, cannabis researcher, and educator—I believe that far more funding needs to go toward rigorous research so that we might truly determine if the various cultivars of cannabis are as promising as they seem in the treatment of mood disorders. The apparent correlation between Kim’s cannabis therapy cessation and her increased PTSD
symptoms appears to provide provocative anecdotal evidence that merits further study.


References

  1. Leadbeater BJ, Ames ME, Linden-Carmichael AN. Agevarying effects of cannabis use frequency and disorder on
    symptoms of psychosis, depression and anxiety in adolescents and adults. Addiction. 2019;114(2):278-293.
  2. Bonaccorso S, Ricciardi A, Zangani C, Chiappini S, Schifano F. Cannabidiol (CBD) use in psychiatric disorders: a systematic review. Neurotoxicology. 2019;74:282-298.
  3. Schmits E, Quertemont E, Boulard, A. Cannabis use and
    depressive mood in adolescence: the mediating/moderating
    role of anxiety, cannabis effect expectancies, and peer
    users. J Child Adoles Subst 2018;5-6:322-333.
  4. Botsford SL, Yang S, George TP. Cannabis and cannabinoids
    in mood and anxiety disorders: impact on illness onset and
    course, and assessment of therapeutic potential [Epub ahead of
    print]. Am J Addict. 2019 Oct 2. doi: 10.1111/ajad.12963.
  5. Bonn-Miller MO, Loflin MJE, Thomas BF, Marcu JP,
    Hyke T, Vandrey R. Labeling accuracy of cannabidiol
    extracts sold online. JAMA. 2017;318(17):1708-1709.
  6. Russo EB. Current therapeutic cannabis controversies and clinical
    trial design issues. Front Pharmacol. 2016;7:309.
  7. Rosado J. A clinical case study of a 45 y/o female suffering with
    PTSD, bipolar D/O, depression, anxiety and chronic pain syndrome
    taking 42-58 pills per day and weaned off of all medications
    using medical cannabis. J Clin Rev Case Reports. 2019;1:1-6.
  8. Shishko I, Oliveira R, Moore TA, Almeida K. A review of medical
    marijuana for the treatment of posttraumatic stress disorder: real
    symptom re-leaf or just high hopes? Ment Health Clin. 2018;8(2):86-94.
  9. Elms L, Shannon S, Hughes S, Lewis N. Cannabidiol
    in the treatment of post-traumatic stress disorder: a case
    series. J Altern Complement Med. 2019;25(4):392-397.