CLINICAL CASE REPORT
Cannabis Withdrawal Syndrome: An Important Diagnostic Consideration in Adolescents Presenting with Disordered Eating Tyler Chesney, MD, MSc1 Laura Matsos, MD, FRCPC2 Jennifer Couturier, MSc, MD, FRCPC2,3,4* Natasha Johnson, MD, FRCPC4
ABSTRACT Although previously thought to have no withdrawal symptoms, there is now convergent evidence for a cannabis withdrawal syndrome (CWS), criteria for its diagnosis, and evidence of its impact in the adolescent population. Cannabis withdrawal syndrome represents an important and underrecognized consideration in adolescents with disordered eating. We describe three clinical cases of adolescents presenting to an eating disorders program with primary complaints of gastrointestinal symptoms, food avoidance, and associated
Introduction There has been a longstanding skepticism concerning the dependence potential of cannabis with beliefs that dependence was rare, occurred in the context of more serious polysubstance abuse, and had minimal consequence.1 Cannabis withdrawal syndrome (CWS) was not included in the DSM-IVTR2 as the clinical significance was uncertain. However, this syndrome now exists in DSM-5.3 The past two decades have seen significant advancements with the discovery of the endogenous cannabinoid system, cannabinoid receptors, and a cannabinoid antagonist enabling the demonstration of withdrawal in animal models.4 Convergent evidence for a true cannabis withdrawal syndrome (CWS) has come from these animal studies along with epidemiological and experimental human studies including both inpatient and outpatient populations of treatment and nontreatment seekers.1,4 The Accepted 1 November 2013 *Correspondence to: Dr. Jennifer Couturier; Department of Psychiatry & Behavioural Neurosciences, McMaster University, ON, Canada. E-mail: [email protected] 1 University of Toronto, Toronto, Ontario, Canada 2 Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ontario, Canada 3 Department of Clinical Epidemiology and Biostatistics, McMaster University, Ontario, Canada 4 Department of Pediatrics, McMaster University, Ontario, Canada Published online 26 November 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.22229 C 2013 Wiley Periodicals, Inc. V
International Journal of Eating Disorders 47:2 219–223 2014
weight loss. They did not meet the criteria for an eating disorder, but did fulfill the DSM-5 criteria for CWS. This report emphasizes the importance of considering the impact of heavy cannabis use in adolescents presenting with gastrointestinal complaints, and eating disorder symptoms, including C 2013 Wiley Periodicals, weight loss. V Inc. Keywords: weight loss
cannabis;
adolescents;
(Int J Eat Disord 2014; 47:219–223)
described withdrawal syndrome has symptoms that are common, occur reliably, have a predictable time course, abate with readministration of cannabis, and are clinically important, resulting in impairment of daily living.1,4,5 The DSM-5 diagnostic criteria for CWS require at least three of seven symptoms that develop within one week of cessation of cannabis use that has been heavy and prolonged.3 The symptoms include; (1) irritability, anger or aggression, (2) nervousness or anxiety, (3) sleep difficulty (insomnia), (4) decreased appetite or weight loss, (5) restlessness, (6) depressed mood, (7) physical symptoms causing significant discomfort from at least one of the following: stomach pain, shakiness/ tremors, sweating, fever, chills, or headache. These symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Finally, the symptoms may not be due to a general medical condition and may not be better accounted for by another disorder. The symptoms of CWS have been shown to have concurrent and predictive validity. In an adolescent sample, four symptoms have been shown to predict severity of cannabis-related problems at 1-year follow-up,6 and in a large adult sample, the DSM-5 CWS diagnosis predicted a shorter duration of abstinence during a quit attempt.7 Subsequent to CWS being identified in the adult population, adolescent studies were undertaken that were suggestive of a similar syndrome.8,9 Withdrawal 219
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is common in outpatient drug treatment seeking adolescents with over one-third having severe withdrawal symptoms.10 An initial prospective study suggested that withdrawal symptoms were most severe in the first 2 weeks of abstinence.11 These symptoms are distressing and are associated with a rapid return to substance use, at least in a population of adolescents with comorbid depression.12 In another prospective study more recent and larger amounts of cannabis use related to more intense withdrawal symptoms, and all symptoms were the most severe on day one of abstinence, declining linearly thereafter.13 Given that the use of cannabis is common in the adolescent age group, it is important that clinicians are aware of the withdrawal syndrome. The Canadian Alcohol and Drug Use Monitoring Survey 2011 reported the lifetime prevalence of cannabis use among individuals 15–24 years to be 34%, with past year cannabis use being 21.6% (Available at: http://www.hc-sc.gc.ca/hc-ps/drugs-drogues/stat/ _2011/summary-sommaire-eng.php). The average age of initiation was 15.6 years among this group. Given the varied symptoms of CWS, this diagnosis is important to consider in the assessment of adolescents with nonspecific GI symptoms and/or disordered eating. In particular, weight loss and abdominal pain are common complaints for adolescents presenting for evaluation of an eating disorder, and are also commonly seen in the CWS. This report describes three adolescents presenting with GI symptoms as a primary concern who, because of associated weight loss and food avoidance, were referred to an eating disorder program for psychiatric evaluation. Each of these adolescents fulfilled the DSM-5 criteria for CWS, but did not meet criteria for an eating disorder. This is the first case series to describe the presentation of CWS to an eating disorders program and emphasizes the importance of considering the impact of cannabis use in adolescents presenting with GI complaints including weight loss. Potentially identifying information has been deleted to maintain confidentiality.
Case Reports Case 1
A 17-year-old male presented with a two year history of daily abdominal pain, nausea, and decreased appetite. These symptoms were more severe in the morning and improved somewhat by the evening, but contributed to considerable food restriction until late in the day. A resultant weight loss of 20 pounds occurred over a period of several 220
weeks that then remained stable. His BMI was 21.4, and he was 90% of his ideal body weight. He denied all purging behaviors and denied guilt about eating. In fact, he wished to gain weight believing he was too thin. Careful screening for the cognitive symptoms of an eating disorder was negative. A thorough work-up by pediatric gastroenterology revealed no organic cause and a trial use of a proton pump inhibitor was not found to be helpful. Notably, he endorsed daily cannabis use for the past four years. At the time of assessment he reported using 2–3 g daily, a decrease from a previous maximum of 12 g daily. Significantly, he stated that he used this as a method to cope with his anxiety. His appetite, abdominal pain, and anxiety improved throughout the day in association with cannabis use. The patient denied sleep disturbances, but noted regular night sweats and chills. He described longstanding concentration difficulties at school, and frequently would leave the classroom after a “build-up” of restlessness. He also endorsed generalized worries on most days for the past three years. At times, he would be quite irritable with his mother and friends. Although he denied any intentional injury to others, he was noted to be prone to anger outbursts and aggression including punching a wall, throwing things, physicality with friends, shoving his mother on a single occasion, and the destruction of an entire panel of drywall in the home. The remainder of the psychiatric history was noncontributory. His past psychiatric history included a negative workup for learning disorders and ADHD as well as family therapy for anger management and parent-child conflict. He had no active medical conditions. Family history was significant for depression and alcohol abuse. Pertinent positives on mental status exam included restlessness, and agitation when confronted with the possibility of decreasing his drug use. Case 2
A 16-year-old female presented with daily nausea, vomiting, impaired appetite, and chronic abdominal pain for multiple years that had worsened in the past year. These symptoms were reported as most severe in the morning and during periods of stress, and aggravated by eating. The patient reported food restriction during the school day and consumed most of her nutrition after school hours. She had lost 20 pounds in the previous three months. She was calculated to be 80% of her ideal body weight. Trials of ranitidine and lansoprazole had not alleviated her symptoms. She International Journal of Eating Disorders 47:2 219–223 2014
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reported using self-induced vomiting and cannabis for relief of abdominal pain. The patient denied vomiting for the purpose of weight loss, and she indicated that she was too thin and wished to gain weight. Cognitions consistent with an eating disorder were not present. An organic cause was not apparent after thorough workup by pediatric gastroenterology. She endorsed cannabis use, smoking up to five times daily for the past three years. Notably, her mother supported this substance use as it provided some relief from her abdominal pain. She denied sleep disturbances and typically had a good level of energy. She described a considerable association of anxiety with her GI symptoms. In particular, her mornings were characterized with a feeling of panic, tachycardia, and breathlessness in association with her GI symptoms. Self-induced vomiting alleviated these symptoms. Further, her school performance, which had deteriorated due to difficulties with concentration, as well as a complicated home situation were additional stressors. The remainder of the psychiatric history was noncontributory. It was not felt that this patient met criteria for an anxiety disorder. Her past psychiatric history included a low mood episode for which she was treated with escitalopram and psychotherapy. She had no active medical conditions. Her medications included escitalopram, esomeprazole, buscopan, and an oral contraceptive pill (desogestrel/ethinyl estradiol). Family history was significant for bipolar disorder, substance abuse, and irritable bowel syndrome. Mental status exam was unremarkable.
addition, she described nearly daily bilateral frontal tension-like headaches with no palliating factors. A GI workup revealed no organic cause. A neurological workup revealed a one centimeter benign pineal cyst with no interval change and no hydrocephalus that was considered noncontributory by neurosurgery. She endorsed daily cannabis use for the previous three years. She reported smoking 4–8 pails daily. A pail is a method of consuming cannabis that involves lifting a bottle with its base removed from a pail of water to produce a suction that creates a reservoir of cannabis smoke for inhalation. Interestingly, she noted that this substance use not only improved her anxiety symptoms but it also relieved her headaches and helped induce sleep. The patient reported sleep initiation difficulties and a low energy level. She tended to be quite anxious with generalized worries. She had several psychosocial stressors, which her mother felt were significant precipitants to her symptoms. She had ongoing symptoms of avoidance and hypervigilience related to a significant witnessed trauma and she was diagnosed with post-traumatic stress disorder. Further, she had become much more distractible and irritable with anger and aggression resulting in verbal fights with family, friends, and teachers. The remainder of the psychiatric history was noncontributory. There was no other past psychiatric history. She had no other active medical conditions. Her medications included amitriptyline, for management of her headaches, and an antireflux medication. Family history was significant for substance abuse, depression, and possible psychosis. Mental status exam was unremarkable.
Case 3
A 16-year-old female presented with a nearly two year history of nausea, vomiting, abdominal discomfort, and decreased appetite that had worsened in the last six months. These daily symptoms would reportedly begin upon awakening and continue throughout the day. At times, vomiting would resolve her symptoms. However, the patient also described a fear of vomiting, and in an attempt to manage her GI symptoms she would regularly restrict her daytime food intake. She denied that these behaviors were associated with intent to lose weight. Despite this, she reportedly lost nearly 20 pounds over a period of nearly a year; however, she wished to gain the weight back. She was estimated to be 85% of her ideal body weight. She denied purging behavior through self-induced vomiting, laxatives, or exercise. Rarely did she exercise. She denied any body weight or shape concerns that would be consistent with an eating disorder. In International Journal of Eating Disorders 47:2 219–223 2014
Discussion In the cases reported the patients presented with nonspecific GI symptoms and food avoidance with associated weight loss in the context of heavy and prolonged use of cannabis. All three reported anxiety/irritability, decreased appetite, and physical symptoms (abdominal discomfort), symptoms that would meet the DSM-5 criteria for CWS. In addition, the symptoms were worse in the morning after awakening from sleep after several hours of abstinence from cannabis use. All three also reported that reinitiation of repeated use of cannabis throughout the day resulted in an improvement in symptoms. This fits with research indicating that withdrawal symptoms are most severe on day one of abstinence.13 All three restricted their food intake during the day to relieve GI discomfort. Two 221
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out of three reported that vomiting alleviated their GI distress. These were likely the symptoms that prompted referral to an eating disorder program. The differential diagnosis in cases such as these could be extensive, including eating disorders, anxiety disorders, and depressive disorders most prominently. Of course, organic conditions are also important to rule out. There is an absence of studies documenting the rate of cannabis use within the eating disorder population; however, given the commonalities in symptom presentation, mood, anxiety, eating and cannabis-use disorders are important to differentiate. Regarding the diagnosis of an eating disorder, restrictive and avoidant eating was prominent in all of these cases; however, careful screening elicited that the intent of these behaviours was related to managing GI upset, rather than losing weight. In fact, in all cases there was an expressed desire to gain weight. In addition, these patients lacked other key criteria for an eating disorder diagnosis. Of significance, there was not a sense of their self-evaluation being unduly influenced by body shape or a documented history of binge eating episodes, or purging behaviour such as laxative use or excessive exercise. There was no noted avoidance of high calorie food, even on collateral history given by parents. The cognitive symptoms of eating disorders were carefully assessed in each of these cases, and were not present. It is important to note that an eating disorder could be co-morbid with cannabis use and withdrawal. For this, we would expect avoidance of high calorie food as well as expressed body image concerns, and other compensatory behaviors such as excessive exercise. In terms of anxiety, the nature of the anxiety in each of these cases was not related to types of food or to weight or shape, but was more general and pervasive. Anxiety was worse in the morning after a period of abstinence from cannabis, and improved when cannabis use was reinitiated. It is important to note that the PTSD symptoms that were comorbid in one of the cases were quite separate and distinct, and were not completely resolved by cannabis use. In terms of depression, none of the three cases described a pervasively depressed mood. Most commonly, an irritable mood was described which improved with cannabis use. None of the patients endorsed suicidal thoughts, or hopelessness and guilt. These cognitive symptoms would be important to elicit in diagnosing a comorbid depressive disorder with CWS, as many patients might endorse physical symptoms such as decreased appetite, sleep, and energy. 222
Another new diagnosis within the DSM-5 is Avoidant/Restrictive Food Intake Disorder (ARFID).3 The criteria for ARFID are met when there is no reported body image concern, but yet there is food avoidance, and at times, weight loss. The criteria state that the eating disturbance is not better explained by another mental disorder. We felt that the eating disturbance was better explained by CWS given the heavy use of this drug, the timing of the symptoms and relief of the symptoms with repeated use. However, the criteria for ARFID also state that when the eating disturbance occurs in the context of another mental disorder and the eating disturbance exceeds that routinely seen with the disorder that an additional diagnosis of ARFID can be given. An argument could be made that an additional diagnosis of ARFID could have been made in these three cases given the extreme nature of the food avoidance and the large loss of weight in each case. The criteria for CWS in the DSM-5 include physical symptoms of stomach pain, decreased appetite, and weight loss.3 Although some reports have indicated increased appetite and weight gain,7,9 the DSM-5 indicates that these symptoms are more congruent with cannabis intoxication. It may be hard at times to tease out the effects of intoxication and withdrawal in a patient who is using cannabis frequently and heavily, and perhaps this is why some papers report increased appetite and weight gain with CWS. Some effort has gone into developing a measure to assess CWS, the cannabis withdrawal scale; which the authors state can be used either as a diagnostic tool, or for monitoring symptoms in clinical and research settings.14 In terms of treatment, there is considerable research on pharmacotherapy for cannabis dependence and withdrawal with some initial efficacy demonstrated for dronabinol, a synthetic oral THC, and gabapentin.15,16 Additionally, there are psychotherapeutic modalities such as motivational enhancement therapy, cognitive-behavioural therapy, contingency management, community and family interventions and combined modalities that demonstrate some efficacy.15 Further research on treatments is needed given the high prevalence of cannabis use in teens. In summary, within this series of three adolescent patients with disordered eating, each one had been referred to an eating disorders program, yet ultimately did not meet criteria for an eating disorder. However, in all of these cases the presenting symptoms did meet the DSM-5 criteria for CWS highlighting the relevance of considering the impact of International Journal of Eating Disorders 47:2 219–223 2014
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heavy cannabis use in this population and the prospects for its treatment. Eating disorders and substance abuse disorders share psychosocial associations and psychiatric comorbidity.17–19 Indeed, disordered eating and nonspecific GI symptoms can present a considerable diagnostic challenge. The newly proposed DSM-5 CWS offers an important and under-recognized diagnostic consideration in concomitant heavy cannabis users presenting with GI complaints, disordered eating, and/or weight loss.
References 1. Budney AJ, Hughes JR. The cannabis withdrawal syndrome. Curr Opin Psychiatry 2006;19:233–238. 2. American Psychiatric Association,Association AP. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision edn. Washington, DC: American Psychiatric Association, 2000. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Association, 2013. 4. Budney AJ, Hughes JR, Moore BA, Vandrey R. Review of the validity and significance of cannabis withdrawal syndrome. Am J Psychiatry 2004;161: 1967–1977. 5. Hasin DS, Keyes KM, Alderson D, Wang S, Aharonovich E, Grant BF. Cannabis withdrawal in the United States: Results from NESARC. J Clin Psychiatry 2008;69:1354–1363. 6. Chung T, Martin CS, Cornelius JR, Clark DB. Cannabis withdrawal predicts severity of cannabis involvement at 1-year follow-up among treated adolescents. Addiction 2008;103:787–799. 7. Gorelick DA, Levin KH, Copersino ML, Heishman SJ, Liu F, Boggs DL, Kelly DL. Diagnostic criteria for cannabis withdrawal syndrome. Drug Alcohol Depend 2012;123:141–147.
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8. Crowley TJ, Macdonald MJ, Whitmore EA, Mikulich SK. Cannabis dependence, withdrawal, and reinforcing effects among adolescents with conduct symptoms and substance use disorders. Drug Alcohol Depend 1998;50: 27–37. 9. Agrawal A, Pergadia ML, Lynskey MT. Is there evidence for symptoms of cannabis withdrawal in the national epidemiologic survey of alcohol and related conditions? Am J Addict 2008;17:199–208. 10. Vandrey R, Budney AJ, Kamon JL, Stanger C. Cannabis withdrawal in adolescent treatment seekers. Drug Alcohol Depend 2005;78:205–210. 11. Milin R, Manion I, Dare G, Walker S. Prospective assessment of cannabis withdrawal in adolescents with cannabis dependence: A pilot study. J Am Acad Child Adolesc Psychiatry 2008;47:174–178. 12. Cornelius JR, Chung T, Martin C, Wood DS, Clark DB. Cannabis withdrawal is common among treatment-seeking adolescents with cannabis dependence and major depression, and is associated with rapid relapse to dependence. Addict Behav 2008;33:1500–1505. 13. Preuss UW, Watzke AB, Zimmermann J, Wong JW, Schmidt CO. Cannabis withdrawal severity and short-term course among cannabis-dependent adolescent and young adult inpatients. Drug Alcohol Depend 2010;106:133– 141. 14. Allsop DJ, Norberg MM, Copeland J, Fu S, Budney AJ. The Cannabis withdrawal scale development: Patterns and predictors of cannabis withdrawal and distress. Drug Alcohol Depend 2011;119:123–129. 15. Danovitch I, Gorelick DA. State of the art treatments for cannabis dependence. Psychiatr Clin North Am 2012;35:309–326. 16. Mason BJ, Crean R, Goodell V, Light JM, Quello S, Shadan F, et al. A proof-ofconcept randomized controlled study of gabapentin: Effects on cannabis use, withdrawal and executive function deficits in cannabis-dependent adults. Neuropsychopharmacology 2012;37:1689–1698. 17. Pisetsky EM, Chao YM, Dierker LC, May AM, Striegel-Moore RH. Disordered eating and substance use in high-school students: Results from the Youth Risk Behavior Surveillance System. Int J Eat Disord 2008;41:464–470. 18. Godart NT, Perdereau F, Rein Z, Berthoz S, Wallier J, Jeammet P, Flament MF. Comorbidity studies of eating disorders and mood disorders. Critical review of the literature. J Affect Disord 2007;97:37–49. 19. Woodside BD, Staab R. Management of psychiatric comorbidity in anorexia nervosa and bulimia nervosa. CNS Drugs 2006;20:655–663.
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Cannabis Withdrawal Syndrome: An Important Diagnostic Consideration in Adolescents Presenting with Disordered Eating Tyler Chesney, MD, MSc1 Laura Matsos, MD, FRCPC2 Jennifer Couturier, MSc, MD, FRCPC2,3,4* Natasha Johnson, MD, FRCPC4
ABSTRACT Although previously thought to have no withdrawal symptoms, there is now convergent evidence for a cannabis withdrawal syndrome (CWS), criteria for its diagnosis, and evidence of its impact in the adolescent population. Cannabis withdrawal syndrome represents an important and underrecognized consideration in adolescents with disordered eating. We describe three clinical cases of adolescents presenting to an eating disorders program with primary complaints of gastrointestinal symptoms, food avoidance, and associated
Introduction There has been a longstanding skepticism concerning the dependence potential of cannabis with beliefs that dependence was rare, occurred in the context of more serious polysubstance abuse, and had minimal consequence.1 Cannabis withdrawal syndrome (CWS) was not included in the DSM-IVTR2 as the clinical significance was uncertain. However, this syndrome now exists in DSM-5.3 The past two decades have seen significant advancements with the discovery of the endogenous cannabinoid system, cannabinoid receptors, and a cannabinoid antagonist enabling the demonstration of withdrawal in animal models.4 Convergent evidence for a true cannabis withdrawal syndrome (CWS) has come from these animal studies along with epidemiological and experimental human studies including both inpatient and outpatient populations of treatment and nontreatment seekers.1,4 The Accepted 1 November 2013 *Correspondence to: Dr. Jennifer Couturier; Department of Psychiatry & Behavioural Neurosciences, McMaster University, ON, Canada. E-mail: [email protected] 1 University of Toronto, Toronto, Ontario, Canada 2 Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ontario, Canada 3 Department of Clinical Epidemiology and Biostatistics, McMaster University, Ontario, Canada 4 Department of Pediatrics, McMaster University, Ontario, Canada Published online 26 November 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.22229 C 2013 Wiley Periodicals, Inc. V
International Journal of Eating Disorders 47:2 219–223 2014
weight loss. They did not meet the criteria for an eating disorder, but did fulfill the DSM-5 criteria for CWS. This report emphasizes the importance of considering the impact of heavy cannabis use in adolescents presenting with gastrointestinal complaints, and eating disorder symptoms, including C 2013 Wiley Periodicals, weight loss. V Inc. Keywords: weight loss
cannabis;
adolescents;
(Int J Eat Disord 2014; 47:219–223)
described withdrawal syndrome has symptoms that are common, occur reliably, have a predictable time course, abate with readministration of cannabis, and are clinically important, resulting in impairment of daily living.1,4,5 The DSM-5 diagnostic criteria for CWS require at least three of seven symptoms that develop within one week of cessation of cannabis use that has been heavy and prolonged.3 The symptoms include; (1) irritability, anger or aggression, (2) nervousness or anxiety, (3) sleep difficulty (insomnia), (4) decreased appetite or weight loss, (5) restlessness, (6) depressed mood, (7) physical symptoms causing significant discomfort from at least one of the following: stomach pain, shakiness/ tremors, sweating, fever, chills, or headache. These symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Finally, the symptoms may not be due to a general medical condition and may not be better accounted for by another disorder. The symptoms of CWS have been shown to have concurrent and predictive validity. In an adolescent sample, four symptoms have been shown to predict severity of cannabis-related problems at 1-year follow-up,6 and in a large adult sample, the DSM-5 CWS diagnosis predicted a shorter duration of abstinence during a quit attempt.7 Subsequent to CWS being identified in the adult population, adolescent studies were undertaken that were suggestive of a similar syndrome.8,9 Withdrawal 219
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is common in outpatient drug treatment seeking adolescents with over one-third having severe withdrawal symptoms.10 An initial prospective study suggested that withdrawal symptoms were most severe in the first 2 weeks of abstinence.11 These symptoms are distressing and are associated with a rapid return to substance use, at least in a population of adolescents with comorbid depression.12 In another prospective study more recent and larger amounts of cannabis use related to more intense withdrawal symptoms, and all symptoms were the most severe on day one of abstinence, declining linearly thereafter.13 Given that the use of cannabis is common in the adolescent age group, it is important that clinicians are aware of the withdrawal syndrome. The Canadian Alcohol and Drug Use Monitoring Survey 2011 reported the lifetime prevalence of cannabis use among individuals 15–24 years to be 34%, with past year cannabis use being 21.6% (Available at: http://www.hc-sc.gc.ca/hc-ps/drugs-drogues/stat/ _2011/summary-sommaire-eng.php). The average age of initiation was 15.6 years among this group. Given the varied symptoms of CWS, this diagnosis is important to consider in the assessment of adolescents with nonspecific GI symptoms and/or disordered eating. In particular, weight loss and abdominal pain are common complaints for adolescents presenting for evaluation of an eating disorder, and are also commonly seen in the CWS. This report describes three adolescents presenting with GI symptoms as a primary concern who, because of associated weight loss and food avoidance, were referred to an eating disorder program for psychiatric evaluation. Each of these adolescents fulfilled the DSM-5 criteria for CWS, but did not meet criteria for an eating disorder. This is the first case series to describe the presentation of CWS to an eating disorders program and emphasizes the importance of considering the impact of cannabis use in adolescents presenting with GI complaints including weight loss. Potentially identifying information has been deleted to maintain confidentiality.
Case Reports Case 1
A 17-year-old male presented with a two year history of daily abdominal pain, nausea, and decreased appetite. These symptoms were more severe in the morning and improved somewhat by the evening, but contributed to considerable food restriction until late in the day. A resultant weight loss of 20 pounds occurred over a period of several 220
weeks that then remained stable. His BMI was 21.4, and he was 90% of his ideal body weight. He denied all purging behaviors and denied guilt about eating. In fact, he wished to gain weight believing he was too thin. Careful screening for the cognitive symptoms of an eating disorder was negative. A thorough work-up by pediatric gastroenterology revealed no organic cause and a trial use of a proton pump inhibitor was not found to be helpful. Notably, he endorsed daily cannabis use for the past four years. At the time of assessment he reported using 2–3 g daily, a decrease from a previous maximum of 12 g daily. Significantly, he stated that he used this as a method to cope with his anxiety. His appetite, abdominal pain, and anxiety improved throughout the day in association with cannabis use. The patient denied sleep disturbances, but noted regular night sweats and chills. He described longstanding concentration difficulties at school, and frequently would leave the classroom after a “build-up” of restlessness. He also endorsed generalized worries on most days for the past three years. At times, he would be quite irritable with his mother and friends. Although he denied any intentional injury to others, he was noted to be prone to anger outbursts and aggression including punching a wall, throwing things, physicality with friends, shoving his mother on a single occasion, and the destruction of an entire panel of drywall in the home. The remainder of the psychiatric history was noncontributory. His past psychiatric history included a negative workup for learning disorders and ADHD as well as family therapy for anger management and parent-child conflict. He had no active medical conditions. Family history was significant for depression and alcohol abuse. Pertinent positives on mental status exam included restlessness, and agitation when confronted with the possibility of decreasing his drug use. Case 2
A 16-year-old female presented with daily nausea, vomiting, impaired appetite, and chronic abdominal pain for multiple years that had worsened in the past year. These symptoms were reported as most severe in the morning and during periods of stress, and aggravated by eating. The patient reported food restriction during the school day and consumed most of her nutrition after school hours. She had lost 20 pounds in the previous three months. She was calculated to be 80% of her ideal body weight. Trials of ranitidine and lansoprazole had not alleviated her symptoms. She International Journal of Eating Disorders 47:2 219–223 2014
CANNABIS WITHDRAWAL IN ADOLESCENTS
reported using self-induced vomiting and cannabis for relief of abdominal pain. The patient denied vomiting for the purpose of weight loss, and she indicated that she was too thin and wished to gain weight. Cognitions consistent with an eating disorder were not present. An organic cause was not apparent after thorough workup by pediatric gastroenterology. She endorsed cannabis use, smoking up to five times daily for the past three years. Notably, her mother supported this substance use as it provided some relief from her abdominal pain. She denied sleep disturbances and typically had a good level of energy. She described a considerable association of anxiety with her GI symptoms. In particular, her mornings were characterized with a feeling of panic, tachycardia, and breathlessness in association with her GI symptoms. Self-induced vomiting alleviated these symptoms. Further, her school performance, which had deteriorated due to difficulties with concentration, as well as a complicated home situation were additional stressors. The remainder of the psychiatric history was noncontributory. It was not felt that this patient met criteria for an anxiety disorder. Her past psychiatric history included a low mood episode for which she was treated with escitalopram and psychotherapy. She had no active medical conditions. Her medications included escitalopram, esomeprazole, buscopan, and an oral contraceptive pill (desogestrel/ethinyl estradiol). Family history was significant for bipolar disorder, substance abuse, and irritable bowel syndrome. Mental status exam was unremarkable.
addition, she described nearly daily bilateral frontal tension-like headaches with no palliating factors. A GI workup revealed no organic cause. A neurological workup revealed a one centimeter benign pineal cyst with no interval change and no hydrocephalus that was considered noncontributory by neurosurgery. She endorsed daily cannabis use for the previous three years. She reported smoking 4–8 pails daily. A pail is a method of consuming cannabis that involves lifting a bottle with its base removed from a pail of water to produce a suction that creates a reservoir of cannabis smoke for inhalation. Interestingly, she noted that this substance use not only improved her anxiety symptoms but it also relieved her headaches and helped induce sleep. The patient reported sleep initiation difficulties and a low energy level. She tended to be quite anxious with generalized worries. She had several psychosocial stressors, which her mother felt were significant precipitants to her symptoms. She had ongoing symptoms of avoidance and hypervigilience related to a significant witnessed trauma and she was diagnosed with post-traumatic stress disorder. Further, she had become much more distractible and irritable with anger and aggression resulting in verbal fights with family, friends, and teachers. The remainder of the psychiatric history was noncontributory. There was no other past psychiatric history. She had no other active medical conditions. Her medications included amitriptyline, for management of her headaches, and an antireflux medication. Family history was significant for substance abuse, depression, and possible psychosis. Mental status exam was unremarkable.
Case 3
A 16-year-old female presented with a nearly two year history of nausea, vomiting, abdominal discomfort, and decreased appetite that had worsened in the last six months. These daily symptoms would reportedly begin upon awakening and continue throughout the day. At times, vomiting would resolve her symptoms. However, the patient also described a fear of vomiting, and in an attempt to manage her GI symptoms she would regularly restrict her daytime food intake. She denied that these behaviors were associated with intent to lose weight. Despite this, she reportedly lost nearly 20 pounds over a period of nearly a year; however, she wished to gain the weight back. She was estimated to be 85% of her ideal body weight. She denied purging behavior through self-induced vomiting, laxatives, or exercise. Rarely did she exercise. She denied any body weight or shape concerns that would be consistent with an eating disorder. In International Journal of Eating Disorders 47:2 219–223 2014
Discussion In the cases reported the patients presented with nonspecific GI symptoms and food avoidance with associated weight loss in the context of heavy and prolonged use of cannabis. All three reported anxiety/irritability, decreased appetite, and physical symptoms (abdominal discomfort), symptoms that would meet the DSM-5 criteria for CWS. In addition, the symptoms were worse in the morning after awakening from sleep after several hours of abstinence from cannabis use. All three also reported that reinitiation of repeated use of cannabis throughout the day resulted in an improvement in symptoms. This fits with research indicating that withdrawal symptoms are most severe on day one of abstinence.13 All three restricted their food intake during the day to relieve GI discomfort. Two 221
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out of three reported that vomiting alleviated their GI distress. These were likely the symptoms that prompted referral to an eating disorder program. The differential diagnosis in cases such as these could be extensive, including eating disorders, anxiety disorders, and depressive disorders most prominently. Of course, organic conditions are also important to rule out. There is an absence of studies documenting the rate of cannabis use within the eating disorder population; however, given the commonalities in symptom presentation, mood, anxiety, eating and cannabis-use disorders are important to differentiate. Regarding the diagnosis of an eating disorder, restrictive and avoidant eating was prominent in all of these cases; however, careful screening elicited that the intent of these behaviours was related to managing GI upset, rather than losing weight. In fact, in all cases there was an expressed desire to gain weight. In addition, these patients lacked other key criteria for an eating disorder diagnosis. Of significance, there was not a sense of their self-evaluation being unduly influenced by body shape or a documented history of binge eating episodes, or purging behaviour such as laxative use or excessive exercise. There was no noted avoidance of high calorie food, even on collateral history given by parents. The cognitive symptoms of eating disorders were carefully assessed in each of these cases, and were not present. It is important to note that an eating disorder could be co-morbid with cannabis use and withdrawal. For this, we would expect avoidance of high calorie food as well as expressed body image concerns, and other compensatory behaviors such as excessive exercise. In terms of anxiety, the nature of the anxiety in each of these cases was not related to types of food or to weight or shape, but was more general and pervasive. Anxiety was worse in the morning after a period of abstinence from cannabis, and improved when cannabis use was reinitiated. It is important to note that the PTSD symptoms that were comorbid in one of the cases were quite separate and distinct, and were not completely resolved by cannabis use. In terms of depression, none of the three cases described a pervasively depressed mood. Most commonly, an irritable mood was described which improved with cannabis use. None of the patients endorsed suicidal thoughts, or hopelessness and guilt. These cognitive symptoms would be important to elicit in diagnosing a comorbid depressive disorder with CWS, as many patients might endorse physical symptoms such as decreased appetite, sleep, and energy. 222
Another new diagnosis within the DSM-5 is Avoidant/Restrictive Food Intake Disorder (ARFID).3 The criteria for ARFID are met when there is no reported body image concern, but yet there is food avoidance, and at times, weight loss. The criteria state that the eating disturbance is not better explained by another mental disorder. We felt that the eating disturbance was better explained by CWS given the heavy use of this drug, the timing of the symptoms and relief of the symptoms with repeated use. However, the criteria for ARFID also state that when the eating disturbance occurs in the context of another mental disorder and the eating disturbance exceeds that routinely seen with the disorder that an additional diagnosis of ARFID can be given. An argument could be made that an additional diagnosis of ARFID could have been made in these three cases given the extreme nature of the food avoidance and the large loss of weight in each case. The criteria for CWS in the DSM-5 include physical symptoms of stomach pain, decreased appetite, and weight loss.3 Although some reports have indicated increased appetite and weight gain,7,9 the DSM-5 indicates that these symptoms are more congruent with cannabis intoxication. It may be hard at times to tease out the effects of intoxication and withdrawal in a patient who is using cannabis frequently and heavily, and perhaps this is why some papers report increased appetite and weight gain with CWS. Some effort has gone into developing a measure to assess CWS, the cannabis withdrawal scale; which the authors state can be used either as a diagnostic tool, or for monitoring symptoms in clinical and research settings.14 In terms of treatment, there is considerable research on pharmacotherapy for cannabis dependence and withdrawal with some initial efficacy demonstrated for dronabinol, a synthetic oral THC, and gabapentin.15,16 Additionally, there are psychotherapeutic modalities such as motivational enhancement therapy, cognitive-behavioural therapy, contingency management, community and family interventions and combined modalities that demonstrate some efficacy.15 Further research on treatments is needed given the high prevalence of cannabis use in teens. In summary, within this series of three adolescent patients with disordered eating, each one had been referred to an eating disorders program, yet ultimately did not meet criteria for an eating disorder. However, in all of these cases the presenting symptoms did meet the DSM-5 criteria for CWS highlighting the relevance of considering the impact of International Journal of Eating Disorders 47:2 219–223 2014
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heavy cannabis use in this population and the prospects for its treatment. Eating disorders and substance abuse disorders share psychosocial associations and psychiatric comorbidity.17–19 Indeed, disordered eating and nonspecific GI symptoms can present a considerable diagnostic challenge. The newly proposed DSM-5 CWS offers an important and under-recognized diagnostic consideration in concomitant heavy cannabis users presenting with GI complaints, disordered eating, and/or weight loss.
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