Can cannabis trigger recurrent panic attacks in susceptible patients?

Cannabis and Anxiety: A Critical Review

Introduction

Cannabis has been reported to have both anxiogenic and anxiolytic effects. Habitual cannabis use has been associated with anxiety disorders (AD). The causal pathways and mechanisms underlying the association between cannabis use (CU)/cannabis use disorder (CUD) and anxiety remain unclear. We examined the literature via a systematic review to investigate the link between cannabis and anxiety. The hypotheses studied include causality, the common factor theory, and the self-medication hypothesis.

Methods

Critical systematic review of published literature examining the relationship of CU/CUD to AD or state-anxiety, including case reports, literature reviews, observational studies, and preclinical and clinical studies. A systematic MEDline search was conducted of terms including: [anxiety], [anxiogenic], [anxiolytic], [PTSD], [OCD], [GAD], [cannabis], [marijuana], [tetrahydrocannabinol], [THC].

Results

While several case-control and cohort studies have reported no correlation between CU/CUD and AD or state anxiety (N = 5), other cross-sectional, and longitudinal studies report significant relationships (N = 20). Meta-analysis supports anxiety correlating with CU (N = 15 studies, OR = 1.24, 95% CI: 1.06-1.45, p = 0.006) or CUD (N = 13 studies, OR = 1.68, 95% CI: 1.23-2.31, p = 0.001). PATH analysis identifies the self-medication hypothesis (N = 8) as the model that best explains the association between CU/CUD and AD or state-anxiety. Despite the support of multiple large cohort studies, causal interpretations (N = 17) are less plausible, while the common factor theory (N = 5), stress-misattribution hypothesis, and reciprocal feedback theory lack substantial evidential support.

Conclusion

The association between cannabis and anxiety is best explained by anxiety predisposing individuals toward CU as a method of self-medication. A causal relationship in which CU causes AD incidence is less likely despite multiple longitudinal studies suggesting so.

A Case of Panic Attacks Developing After 10 Years of Chronic Cannabis Use in a Patient With No Prior Psychiatric History

Cannabis use for medical and recreational purposes is increasing. Inhibitory activity of cannabinoids (CB) at the CB1 and CB2 receptors centrally and peripherally mediate the therapeutic effects that are wielded for palliation of pain, anxiety, inflammation, and nausea in indicated conditions. Cannabis dependence is also associated with anxiety; however, the direction of causality is unknown, such as whether anxiety disorders lead to cannabis use, or whether cannabis contributes to the development of anxiety disorder. The evidence hints that both may have validity. Here we present a case of cannabis-associated panic attacks following 10 years of chronic cannabis dependence in an individual with no prior psychiatric history. The patient is a 32-year-old male with no significant past medical history who presented complaining of five-minute episodes of palpitations, dyspnea, upper extremity paresthesia, subjective tachycardia, and cold diaphoresis occurring in a variety of circumstances for the past two years. His social history was significant for 10 years of smoking marijuana multiple times daily, which he had quit over two years ago. The patient denied past psychiatric history or known anxiety problems. Symptoms were unrelated to activity and only relieved with deep breathing. The episodes were not associated with chest pain, syncope, headache, or emotional triggers. The patient had no family history of cardiac disease or sudden death. The episodes were refractory to the elimination of caffeine, alcohol, or other sugary beverages. The patient had already stopped smoking marijuana when the episodes began. Due to the unpredictable nature of the episodes, the patient reported a growing fear of being in public. On laboratory workup, metabolic and blood panels were within normal limits, as well as thyroid studies. Electrocardiogram showed normal sinus rhythm, and continuous cardiac monitoring revealed no arrhythmias or abnormalities despite the patient indicating multiple triggered events within the duration of monitoring. Echocardiography also showed no abnormalities. With organic cardiac causes of the subjective palpitation episodes ruled out, a psychogenic etiology of the episodes was presumed, and the patient was referred to behavioral health services. In conclusion, cannabis-induced anxiety or panic disorders should be considered in patients with no prior psychiatric history presenting with anxiety-like attacks following a period of cannabis dependence or current use. These patients should be advised to cease cannabis use and referred to behavioral medicine.

Nonmedical Cannabis Use: Patterns and Correlates of Use, Exposure, and Harm, and Cancer Risk

Cannabis has certain health benefits, but some people may experience harms from use. Co-use of tobacco and cannabis is common. Smoke from cannabis contains many of the same carcinogens and toxicants as the smoke from tobacco, raising concerns that cannabis smoking may be a risk factor for cancer. With growing access to and acceptance of medical and nonmedical cannabis, there is an urgent need to understand the risks and benefits of the current modes of cannabis use and how cannabis may be associated with cancer risk. This monograph summarizes a session from a National Cancer Institute Symposium on nonmedical cannabis use and cancer risk. We had 3 objectives: describe the relation between nonmedical cannabis use and cancer risk, delineate patterns and correlates of cannabis co-use with tobacco, and document potentially harmful inhalational exposure resulting from smoked and vaped cannabis. Methodological limitations in the literature and future research recommendations are provided.

The Periaqueductal Gray and Its Extended Participation in Drug Addiction Phenomena

The periaqueductal gray (PAG) is a complex mesencephalic structure involved in the integration and execution of active and passive self-protective behaviors against imminent threats, such as immobility or flight from a predator. PAG activity is also associated with the integration of responses against physical discomfort (e.g., anxiety, fear, pain, and disgust) which occurs prior an imminent attack, but also during withdrawal from drugs such as morphine and cocaine. The PAG sends and receives projections to and from other well-documented nuclei linked to the phenomenon of drug addiction including: (i) the ventral tegmental area; (ii) extended amygdala; (iii) medial prefrontal cortex; (iv) pontine nucleus; (v) bed nucleus of the stria terminalis; and (vi) hypothalamus. Preclinical models have suggested that the PAG contributes to the modulation of anxiety, fear, and nociception (all of which may produce physical discomfort) linked with chronic exposure to drugs of abuse. Withdrawal produced by the major pharmacological classes of drugs of abuse is mediated through actions that include participation of the PAG. In support of this, there is evidence of functional, pharmacological, molecular. And/or genetic alterations in the PAG during the impulsive/compulsive intake or withdrawal from a drug. Due to its small size, it is difficult to assess the anatomical participation of the PAG when using classical neuroimaging techniques, so its physiopathology in drug addiction has been underestimated and poorly documented. In this theoretical review, we discuss the involvement of the PAG in drug addiction mainly via its role as an integrator of responses to the physical discomfort associated with drug withdrawal.

The role of cannabis in treating anxiety: an update

PURPOSE OF REVIEW

Cannabis use for medical purposes has become increasingly common, including as treatment for mental health disorders such as anxiety. Unfortunately, the evidence examining its use in mental health has been slow to evolve, but is emerging. Given the widespread use of cannabis, it is important for both clinicians and those who suffer with anxiety to understand the effects of cannabis on symptoms of anxiety. In this review, we present recent, available evidence from animal models, clinical trials, and survey studies and evaluate the contribution of these studies to the current understanding of the role of cannabis in treating anxiety.

RECENT FINDINGS

In reviewing recent evidence, we observed significant inconsistencies across findings from preclinical studies. Large-scale surveys suggest that cannabis may be effective in reducing anxiety, however, these results stand in contrast to equivocal findings from clinical trials.

SUMMARY

The literature evaluating the efficacy of cannabis in anxiety disorders is in its infancy. The survey data is generally positive. Although, while some animal studies posit cannabis constituents to have anxiolytic effects, others suggest the opposite or null results. Few new clinical trials have been conducted recently, and the extant trials have significant flaws in methodology. Although anecdotal evidence from survey studies, and a small signal found in animal studies and single-dose clinical trials provide early support that cannabis may be effective for alleviating anxiety, ultimately, the current evidence is equivocal. More high-quality clinical trials must be published before sound conclusions regarding the efficacy of cannabis for treating anxiety can be drawn.

Patterns of the co-use of alcohol, marijuana, and emerging tobacco products in a national sample of young adults

BACKGROUND

Emerging tobacco product use is on the rise in young adults and has been linked to alcohol and marijuana use. Little is known about which patterns of alcohol, marijuana, and emerging tobacco product co-use are most popular in this age group.

OBJECTIVES

This study examined the prevalence of a broad spectrum of marijuana, alcohol, and tobacco co-use patterns across a variety of tobacco products in a national sample of young adults.

METHODS

Data were analyzed from a sub-set of 18-24 year olds (unweighted n = 3,940) from five waves of the Truth Initiative Young Adult Cohort, a national sample of 18-34 year olds. A user-generated statistical program in R was used to assess all possible patterns of past 30-day use of alcohol, marijuana, cigarettes, cigars, e-cigarettes, little cigars/cigarillos, hookah, and other tobacco (pipe, chew, dip, snus, dissolvables).

RESULTS

No past 30-day use of any substance emerged as the most popular pattern across all years (42%), followed by exclusive past 30-day alcohol use (31%), and past 30-day alcohol use with cigarettes (5%) or marijuana (4%). The popularity of exclusive marijuana use increased over time, but only 1% reported exclusive marijuana use without the combination of either alcohol or a tobacco product. E-cigarette use only emerged in combination with alcohol and was the least popular pattern of co-use relative to other patterns.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Patterns stress the importance of alcohol among young people. Successful substance use prevention should focus on alcohol's co-use with a variety of substances of abuse, rather than focus on a single behavior. (Am J Addict 2016;25:634-640).

Cannabis use and anxiety: is stress the missing piece of the puzzle?

OBJECTIVE

Comorbidity between anxiety and cannabis use is common yet the nature of the association between these conditions is not clear. Four theories were assessed, and a fifth hypothesis tested to determine if the misattribution of stress symptomology plays a role in the association between state-anxiety and cannabis.

METHODS

Three-hundred-sixteen participants ranging in age from 18 to 71 years completed a short online questionnaire asking about their history of cannabis use and symptoms of stress and anxiety.

RESULTS

Past and current cannabis users reported higher incidence of lifetime anxiety than participants who had never used cannabis; however, these groups did not differ in state-anxiety, stress, or age of onset of anxiety. State-anxiety and stress were not associated with frequency of cannabis use, but reported use to self-medicate for anxiety was positively associated with all three. Path analyses indicated two different associations between anxiety and cannabis use, pre-existing and high state-anxiety was associated with (i) higher average levels of intoxication and, in turn, acute anxiety responses to cannabis use; (ii) frequency of cannabis use via the mediating effects of stress and self-medication.

CONCLUSION

None of the theories was fully supported by the findings. However, as cannabis users reporting self-medication for anxiety were found to be self-medicating stress symptomology, there was some support for the stress-misattribution hypothesis. With reported self-medication for anxiety being the strongest predictor of frequency of use, it is suggested that researchers, clinicians, and cannabis users pay greater attention to the overlap between stress and anxiety symptomology and the possible misinterpretation of these related but distinct conditions.

Difficulties in emotion regulation are associated with panic symptom severity following a quit attempt among cannabis dependent veterans

BACKGROUND AND OBJECTIVES

Prior research suggests that difficulties in emotion regulation are associated with elevations in panic symptoms. The present study aimed to extend this work by prospectively examining the relation between difficulties in emotion regulation and panic symptoms over the course of a self-guided cannabis cessation attempt.

DESIGN AND METHOD

One hundred and four cannabis-dependent military veterans participated in the study. Difficulties in emotion regulation and panic symptoms were assessed at baseline and at each week during a four-week cessation attempt for a total of five time-points.

RESULTS

Fewer difficulties in emotion regulation were associated with a greater reduction in panic symptoms during the self-guided cannabis cessation period. RESULTS remained significant after statistically adjusting for mean substance use (i.e., cannabis, alcohol, and tobacco) during the study period.

CONCLUSIONS

RESULTS are discussed in terms of integrating adaptive emotion regulation skills training into existing evidence-based treatments for cannabis dependence.

Cannabis and anxiety: a critical review of the evidence

BACKGROUND

Anxiety reactions and panic attacks are the acute symptoms most frequently associated with cannabis use. Understanding the relationship between cannabis and anxiety may clarify the mechanism of action of cannabis and the pathophysiology of anxiety. Aims of the present study were to review the nature of the relationship between cannabis use and anxiety, as well as the possible clinical, diagnostic and causal implications.

METHOD

Systematic review of the Medline, PsycLIT and EMBASE literature.

RESULTS

Frequent cannabis users consistently have a high prevalence of anxiety disorders and patients with anxiety disorders have relatively high rates of cannabis use. However, it is unclear if cannabis use increases the risk of developing long-lasting anxiety disorders. Many hypotheses have been proposed in an attempt to explain these relationships, including neurobiological, environmental and social influences.

CONCLUSIONS

The precise relationship between cannabis use and anxiety has yet to be established. Research is needed to fully clarify the mechanisms of such the association.

Medication-associated Depersonalization Symptoms: Report of Transient Depersonalization Symptoms Induced by Minocycline

Patients with depersonalization disorder experience episodes in which they have a feeling of detachment from themselves. Symptoms of depersonalization may occur in individuals who have other mental disorders, or who have various medical conditions, or who have taken certain medications. A woman developed depersonalization symptoms after initiation of minocycline therapy. Her symptoms ceased after treatment was stopped and recurred when she restarted the drug. Medications that have been associated with causing symptoms of depersonalization are presented and the postulated pathogenesis by which some of these drugs induced depersonalization symptoms is discussed. Medication-associated depersonalization symptoms typically resolve once the inducing drug has been withdrawn.

Cannabis use and anxiety in daily life: a naturalistic investigation in a non-clinical population

The study's objective was to investigate in a non-clinical population the association between cannabis use and anxiety in daily life using the Experience Sampling Method (ESM). Seventy-nine subjects with high or low levels of cannabis use were selected among a sample of 685 undergraduate university students. ESM was used to collect information on cannabis use and state-anxiety in daily life. DSM-IV diagnoses were assessed using a structured clinical interview. Statistical analyses were performed using multilevel linear random regression models. There was no significant association between the level of state anxiety and cannabis use in daily life. However, a diagnosis of agoraphobia was significantly associated with increased likelihood of cannabis use, independent of state anxiety and other confounding factors. No evidence was found for an anxiolytic or anxiogenic effect of cannabis in daily life. This finding does not support the hypothesis that subjects with high levels of anxiety use cannabis as a means of self-medication. The association between agoraphobia and cannabis use in daily life may be explained by anticipatory anxiety secondary to previous cannabis-induced panic-like symptoms.

Marijuana precipitation of panic disorder with agoraphobia

We report the case of a 16-year-old adolescent with the onset of a panic disorder with agoraphobia after a first panic attack during marijuana intoxication. There was a good response to standard cognitive behavioural therapy for panic disorder.