Smoking to Calm Down, Anxious When He Stops: Treating Cannabis Use Disorder and Generalized Anxiety Together in a 27-Year-Old, When Psychosocial Care Has the Evidence and Pills Mostly Do Not
[Student Name]
University of Phoenix
PMH/504: Psychiatric Management Of Adult And Geriatric Patients
Week 6 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Mr. P., a 27-year-old software tester, has smoked cannabis daily for five years, now several times a day, and says it is the only thing that calms his anxiety. When he tried to stop last month, he became irritable, could not sleep, lost his appetite and felt more anxious than ever, so he restarted. He worries about everything, has muscle tension and trouble concentrating, and his performance reviews have slipped. His GAD-7 score is 16. The sections below set out how his two conditions were separated, what the evidence supports and the plan he agreed to.
The Size of the Problem
Hasin et al. (2016), analyzing a nationally representative survey, estimated the prevalence of DSM-5 cannabis use disorder at 2.5% over 12 months and 6.3% over a lifetime, with higher odds among young adults, men and people with low income, and found that the disorder was associated with other psychiatric conditions and disability and largely untreated. Mr. P., a young adult with anxiety and daily use, fits the profile.
History and Pattern of Use
Mr. P. began using cannabis socially at 19 and daily at 22, after a stressful period at his first job. He now uses high-potency concentrates by vaporizer, about a gram a day, spending roughly $400 a month. He uses on waking and before bed and says he cannot fall asleep without it. He does not use alcohol heavily, denies other drugs and has no history of psychosis. His father had an alcohol problem, and his mother has been treated for anxiety.
Medical and Psychiatric Screening
He has no chest pain or palpitations beyond those with anxiety. He denies suicidal thoughts. There is no history of mania. He reports occasional morning nausea, which can reflect heavy cannabis use; persistent cyclic vomiting would raise concern for cannabinoid hyperemesis syndrome, which he does not have. A urine drug screen is positive only for cannabinoids.
Diagnosis
He meets DSM-5 criteria for moderate cannabis use disorder: using more than intended, failed efforts to cut down, craving, use despite problems at work, tolerance and withdrawal. Whether his anxiety is a primary generalized anxiety disorder or partly cannabis-related matters for treatment.
Sorting Withdrawal From Primary Anxiety
Cannabis withdrawal causes irritability, anxiety, sleep disturbance, decreased appetite and restlessness, typically peaking within the first week and resolving over a few weeks. Much of what he felt when he stopped was withdrawal, which reinforced his belief that cannabis controls his anxiety. His history, however, reveals worry and tension since high school, before regular cannabis use, which suggests a primary generalized anxiety disorder that cannabis has been used to self-medicate.
The anxiety he felt when he stopped proved to him that cannabis helped; it more likely proved that he was in withdrawal.
His Goals
Mr. P. is ambivalent. He wants to feel less anxious and keep his job, but he does not want to give up cannabis entirely. Motivational interviewing starts where he is: we explore what he values, including his career and his relationship with his girlfriend, and how daily use affects them. He sets his own first goal, which is no use before or during work hours for two weeks. This is less than abstinence but gives him a success to build on.
What the Evidence Offers
Gates et al. (2016) reviewed 23 randomized trials of psychosocial interventions for cannabis use disorder and found that psychosocial treatment reduced use compared with minimal treatment, with cognitive behavioral therapy, motivational enhancement therapy and their combination, sometimes with contingency management, among the approaches studied, though abstinence rates were low and unstable. Nielsen et al. (2019), reviewing pharmacotherapies, found incomplete, mostly low-quality evidence, concluding that SSRIs, mixed-action antidepressants, bupropion, buspirone and atomoxetine are probably of little value for cannabis dependence and that other agents remain experimental.
An Integrated Plan
Treating the anxiety and the cannabis use together, rather than insisting he stop cannabis before treating anxiety, keeps him engaged. The plan: motivational enhancement and cognitive behavioral therapy addressing both cannabis use and worry, with skills for managing anxiety without cannabis; a gradual reduction plan agreed with him, rather than abrupt cessation, to limit withdrawal; sleep hygiene and exercise to reduce withdrawal-related insomnia and anxiety; and an SSRI for generalized anxiety disorder, chosen for the anxiety itself, since SSRIs treat generalized anxiety disorder even though they do not treat cannabis dependence (Nielsen et al., 2019).
Managing Withdrawal
Withdrawal symptoms are explained in advance, including their usual peak in the first week and their fading over several weeks, so that he does not read them as proof that his anxiety needs cannabis. Short-term sleep support focuses on a fixed wake time, no screens late at night and exercise earlier in the day. If insomnia is severe, a short course of a non-habit-forming sleep aid can be considered.
Choosing the SSRI
Escitalopram is started at 5 mg for one week, then 10 mg, targeting generalized anxiety disorder. I explain that benefit takes several weeks, that it will not reduce his wish to use cannabis on its own and that its role is to treat the anxiety underneath. Hydroxyzine is available for acute anxiety if needed, since it carries no dependence risk.
What Not to Prescribe
Benzodiazepines would add a second dependence risk and are avoided. Gabapentin has been studied for cannabis use disorder with mixed results and carries misuse potential; I do not start it now.
Relapse Is Expected
Relapse to use is common in cannabis use disorder, and abstinence rates in trials are low (Gates et al., 2016). A lapse is treated as information about his triggers, such as work deadlines or conflict, rather than as failure, and the plan is adjusted.
His Girlfriend
With his consent, his girlfriend is invited to one visit. She learns about withdrawal, how to support his goals without monitoring him and how to reinforce days without use.
Measuring Progress
Days of cannabis use per week and GAD-7 scores are tracked at each visit. A reduction in use days, even before abstinence, is progress. At each visit we also review sleep, work performance and whether his worry is easing, and the SSRI dose is adjusted after six weeks if his GAD-7 remains above 10.
Work
He asks that his employer not be told, and his privacy is respected. His job performance is part of his motivation. We link goals to it: clearer focus and fewer missed deadlines.
Conclusion
Mr. P.'s daily cannabis use and generalized anxiety reinforce each other, with withdrawal anxiety convincing him that cannabis is necessary. National data show that cannabis use disorder is common and largely untreated in young adults. Cochrane evidence supports psychosocial treatment and finds little value in current medications for cannabis dependence, so his integrated plan combines motivational and cognitive behavioral therapy, gradual reduction and an SSRI aimed at his primary anxiety.
References
Gates, P. J., Sabioni, P., Copeland, J., Le Foll, B., & Gowing, L. (2016). Psychosocial interventions for cannabis use disorder. Cochrane Database of Systematic Reviews, 2016(5), Article CD005336. https://doi.org/10.1002/14651858.CD005336.pub4
Hasin, D. S., Kerridge, B. T., Saha, T. D., Huang, B., Pickering, R., Smith, S. M., Jung, J., Zhang, H., & Grant, B. F. (2016). Prevalence and correlates of DSM-5 cannabis use disorder, 2012-2013: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions-III. American Journal of Psychiatry, 173(6), 588-599. https://doi.org/10.1176/appi.ajp.2015.15070907
Nielsen, S., Gowing, L., Sabioni, P., & Le Foll, B. (2019). Pharmacotherapies for cannabis dependence. Cochrane Database of Systematic Reviews, 2019(1), Article CD008940. https://doi.org/10.1002/14651858.CD008940.pub3
How this PMH 504 Week 6 example is structured
The PMH/504 Week 6 work usually addresses co-occurring substance use disorders. This paper treats the substance and the psychiatric condition as linked problems, shows how evidence shapes the order of treatment and explains why integrated care beats sequential care. Students search this week as PMH 504 Week 6, PMH504 Wk 6 or PMH/504 Wk 6; all three are the same assignment.
PMH/504 Week 6 questions, answered
What does PMH/504 Week 6 usually ask for?
Many sections ask students to assess and treat a substance use disorder that co-occurs with another psychiatric condition, using integrated, evidence-based approaches.
How common is cannabis use disorder?
A national survey estimated 12-month and lifetime prevalence of DSM-5 cannabis use disorder at 2.5% and 6.3% of U.S. adults, with higher rates in young adults and most cases untreated.
Are there medications for cannabis use disorder?
No medication is approved, and a Cochrane review found incomplete, mostly low-quality evidence; SSRIs, bupropion and buspirone appear to be of little value, while psychosocial treatments have better support.
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