1

“CASE REPORT”

Cannabis-Induced psychotic disorder, severe

SUBMITTED TO

Dr. Nazia Iqbal

Assistant Professor/ Chairperson Deptt. of Psychology

SUBMITTED BY

KOMAL MAJEED

Roll no: 1570/BSPSY/FSS/F2020

BS 8(B)

Department of Psychology

INTERNATIONAL ISLAMIC UNIVERSITY

ISLAMABAD
 2

Case 1

304.30 (F12.20) cannabis use disorder, moderate

 3

Summary of case:

R.R was a 24 years old man. The client was referred to the trainee clinical psychologist in Shifa
caring and medical center for psychological assessment and management of difficulty
aggressiveness, exhaustion, irritability, paranoia, auditory hallucinations and sleep problems.
Informal assessment was done that includes detailed intake history, mental status examination,
and behavior observation. Formal assessment such as DSM 5 TR diagnostic criteria, House Tree
Person, Drug Abuse Screening Test and brief psychotic rating scale was administered. The DAST
score was 7 that was the indicator of severe level of problem whereas score on BPRS was 64
which was also an indicator of severe psychoses. On the basis of obtained results, the client was
diagnosed with cannabis-Induced Psychotic Disorder. For the purpose of management rapport
building, psycho education, relaxation techniques, cost-benefit analysis, and relapse prevention
plan were used. The overall outcome of the process was satisfactory.

Identifying information:

Bio Data

Name: R. R

Age: 24 years

Gender: Male

Education: Matric

Profession: carpenter

Number of siblings: 4

Birth order: second

Marital Status: single

 4

Socioeconomic Status: Middle class

Family System: Nuclear

Religion: Islam

Referred By: uncle

Reason and Source of Referral

The client was referred to the trainee clinical psychologist in Shifa caring and medical
Centre for psychological assessment and management of aggressiveness, exhaustion, irritability,
agitation, paranoia, auditory hallucinations, sleep problem from last 7 years.

Presenting Complaints:

Bohat saal pehly doston k sath nasha karta tha. Ghussa itna ziada aata tha k ghar se bhaag jata tha
or poori raat hi ghar sy bahir guzar deta tha. Ajeeb khayal aata hy k koi mjhe pakar le ga. Aksar
raat ko violin ki awaz aati thi or neend bohat kharab ho gai h..

Initial observation:

Mental State Examination revealed a young male, groomed, calm but looks not very confident.
He was wearing shalwar and qameez. His appearance was consistent with his reported age. He
was neat and tidy heighted man of average weight.

History of present illness:

Problem started about 7 years ago when he was introduced to cannabis by his friends. He started
by smoking two drags from a friend’s cigarette, which made him feel really good. He continued
and gradually increased his intake day initially. He had to increase the amount smoked at reach
time in other to achieve desired effects he usually gets from lower quantities. He has made
several failed attempts to stop using the cannabis in the past. He claims to take these to slow
down, relax and sleep well. He also reported that most of the time he used to go to the graveyard,
sit there for a long time and smoke. It gave him peace and calmed his soul. Later on, his family
 5

noticed that he was talking irrationally while under the influence of cannabis. His condition
became increasingly worse over the period preceding presentation. He was also seen to be
exhibiting odd behaviors like gets angry on every little things, he used to run away from the
home and sleep on the footpath. He was involved in a fight with some friends who put him in a
state of rage and paranoid state as he reported that he had strange thoughts that someone would
catch me and his friends ganged up against him and they were planning to kill him. Client also
reported that he used to hear the sounds of violin especially at night time. Apart from this he also
reported the history of sustained low mood, poor sleep and appetite.

Background information:

Personal history:

The client was born through normal delivery and all of the developmental milestones of the client
were also age-appropriate. Client’s schooling was of a government school. His education was till
matric. He was below average student. The client’s relationship with his teachers, fellows and
friends was satisfactory. According to him, He was not a brilliant student and not even particular
interest in studies. He used to make practical notebooks for the fellows as he was very good in
drawing. Furthermore he likes cricket. After passing the matric he learned the wood work and
then worked as a carpenter with his uncle for a long time. And then start this as a private business
and he reported that this work benefited him a lot. The household expenses came out comfortably
from this work. Client was not very social. He had limited friends. Client’s friends were already
involved in smoking and drug uses. He also started smoking cigarette and cannabis under the
influence of his company. He reported that he had good relationships and bounding with friends
but later on he involved in a fight with some friends who put him in a state of rage and paranoid
state as he reported that he had strange thoughts that someone would catch me and his friends
ganged up against him and they were planning to kill him. The client was not married yet. He
likes a girl in his neighborhood and even his family knows about this relationship. He reported
that after leaving from here he will send proposal to her. The client had not any significant
forensic history. He was once admitted to the same center in 2017 under the treatment of the
same drug such as cannabis used for three months. Other than that past medical and surgical
history was non-significant.

Family History

The client belonged to middle class family and lived in a joint family system in Ayubia. His
father died in 2003 as client reported that his father had a history of epilepsy. He reported that he
 6

didn’t know much about his father because he was very young when his father died. Client’s
mother was by nature a generous person. Most of the attachment and sharing was with mother.
He had two brothers and two sisters. His brothers are married and one brother lives with them.
Client had good and pleasant relationship with his brother, they shared a good communication
pattern, friendly relation and share a good interaction pattern while he had not satisfactory
relationship with his one sister as he reported his sister used to fight with him in household
chores and for job. Overall the family environment was supportive and there were family time at
his house in which they were sits together, talks on daily activities and eats together. According
to him family is best. There was epileptic history in the family he also reported that his cousins
also have positive history of drug use.

Educational history:

. According to him, He was not a brilliant student and not even particular interest in studies. He
used to make practical notebooks for the fellows as he was very good in drawing. Furthermore he
likes cricket.

Occupational history:

After passing the matric he learned the wood work and then worked as a carpenter with
his uncle for a long time. And then start this as a private business and he reported that this work
benefited him a lot. The household expenses came out comfortably from this work.

Sexual history:

After starting he get involved and interest in watching porn videos. Client also reported to be
indulged in sexual activity with his friend at age 20. He had proper sexual relationship with his
girlfriend .According to client, he had strong sense of guilt associated with his relation with
girlfriend, although he wants to marry her.

Social history:

Client was not very social. He had limited friends. Client’s friends were already involved in
smoking and drug uses. He also started smoking cigarette and cannabis under the influence of his
company. He reported that he had good relationships and bounding with friends but later on he
involved in a fight with some friends who put him in a state of rage and paranoid state as he
 7

reported that he had strange thoughts that someone would catch me and his friends ganged up
against him and they were planning to kill him.

Client’s premorbid personality:

He had a pre morbid personality of being not very social, active and outgoing but stubborn and
aggressive nature. His decision making power was not very good. He was most interested in
cricket, playing video games and drawings. His stress coping strategies was not very good and he
used to get upset and aggressive on every little things.

History of family psychiatry/ medical illness:

There was epileptic history in the family he also reported that his cousins also have positive
history of drug use.

Psychological assessment:

In order to assess the client’s problem two types of assessment were carried out that was:

• Informal assessment

• Formal assessment

Informal assessment:

The informal assessment comprised of:

• Clinical Interview

• Mental Status Examination

• Subjective Rating of Problems

Formal Assessment
 8

The formal assessment comprised of

• DSM-5 criteria of Cannabis Use psychotic Disorder

• DAST-10

• HTP

Informal Assessment

Clinical Interview

Clinical interview was conducted with the client to get detailed information about his

family, personal and the history of psychiatric problem. The client had proper insight about his

problem, and it seems that was motivated to seek treatment. During the complete interview

session the client was very complaint, and was cooperative.

Mental Status Examination

MSE is done with Client at first presentation to the clinical psychologist to assess about

client’s verbal & nonverbal symptoms of illness. Mental State Examination revealed a young

male, groomed, calm but looks not very confident. He was wearing shalwar and qameez. His

appearance was consistent with his reported age. He was neat and tidy heighted man of average

weight. He was cooperative, responded well to questions asked and maintained considerable eye

contact. No abnormal involuntary motor movements. His speech was spontaneous, coherent, and

relevant with normal tone, volume and rate. The content of speech was mostly contain the

aggressive and paranoid content. He described his mood and the mood and effect both are

congruent. His orientation was good as he responded accurately when asked about the place,

season, year, date, month, time and city. There was auditory hallucination. His cognition was fare

and she had good test judgment and full insight.

Subjective Rating of Problems

 9

The Ratings of symptoms of the Client were taken from the client himself as he had proper

insight about his problem. The ratings of symptoms of client’s problem were taken with the

purpose of obtaining the severity of client’s problematic behavior, and also to see that how much

the client perceives his problem. Ratings were taken through 0-10 scale, in which “0” means “no

problem at all”, and “10”means“severe problems. The ratings of client suggests that the client,

had craving of drug along with other symptoms that are more prominent.

Table 1

Subjective rating of problematic behavior of Client at pre-intervention level

Problematic Areas Pre-Intervention Rating

Aggressiveness 9

Exhaustion 8

Irritability 7

Paranoia 9

Auditory hallucination 9

Sleep problems 8

Formal assessment:

Drug abuse screening test (DAST-10)

The test questions were asked in the form of interview from the client. It took 10-18 minutes to
administer the test. The client seems motivated for the test. Proper instructions were provided to
him before the test was started.

Client’s score Range Severity Level

7 5 -10 severe level

Qualitative Analysis:
 10

The DAST was administered to know the previous severity level of the problem of the client
when he was involved in substance abuse. Client’s score on DAST is 7, that falls in the
maximum category of range. The score suggests that the client was in severe level of problem
before the withdrawal occurs. Client’s score suggest his marked decline in functioning,
relationship problems, and lack of self-control. Client’s background information is also
supporting the test results.

House Tree Person Test (See Appendix 2.C)

Qualitative Analysis Client’s performance on the House Tree Person shows the continuing
themes of frustration, child abuse and frightened fantasies. It also indicate that client had
aggressive personality. The client appeared antisocial tendencies and psychotic features. Case
Formulation The client was 24-year-old male, belong to a middle-class. The presenting complaint
of the client was aggressiveness, exhaustion, irritability, agitation, paranoia, auditory
hallucinations, and sleep problem. As client was a young adult of 24 years his age may be a
strong predisposing factor. Many studies have established that drug use is at its peak in the age
range of 15-25 years. Research suggests that cannabis use during adolescence and young
adulthood is associated with an increased risk of developing psychosis (Marconi et al., 2016).
The client's age falls within the range of increased vulnerability to cannabis-induced psychosis.
Peer pressure plays a significant role in initiating and maintaining drug use, including cannabis
(Degenhardt et al., 2010). The client's social circle may have influenced his decision to start
using drugs. Family members, especially close relatives, can influence an individual's drug use
behavior (Silins et al., 2018). The client's cousin's drug use might have exposed him to cannabis
and increased his curiosity and experimentation.

Tentative Diagnosis

304.40(F12.959), cannabis-Induced Psychotic Disorder, severe

Case Formulation:

The client was 40 years old male, belong to a middle-class. The presenting complaint of the
client was elevated mood, racing thoughts, over talkative, religious grandiosity, restless and
aggression. The client's age of 40 suggests a long-standing vulnerability to the development of
bipolar disorder. Age is a predisposing factor as bipolar disorder typically manifests in late
adolescence or early adulthood (American Psychiatric Association, 2013). The death of
the client's mother in childhood could be a precipitating factor in the development of bipolar
 11

disorder. Early loss of a parent has been associated with increased risk for various mental health
conditions, including bipolar disorder (Malkoff-Schwartz et al., 1998). The emotional impact of
this loss may have contributed to the onset of manic episodes.

The father's other marriages may have contributed to ongoing stress and disruption within
the client's family environment. Unstable family dynamics can perpetuate the symptoms of
bipolar disorder (Miklowitz & Johnson, 2009), potentially exacerbating manic episodes. The
client's unwanted marriage could serve as a perpetuating factor, leading to additional stress and
emotional turmoil. Marital distress has been linked to the course and severity of bipolar disorder
(Whisman et al., 2006), and the client's marital situation may contribute to the recurrence of
manic episodes.

The presence of a supportive family can act as a protective factor in managing bipolar
disorder. A supportive environment, characterized by understanding, empathy, and emotional
support, can help mitigate the impact of stress and promote effective coping strategies (Johnson
et al., 2012). The client's supportive family may provide a valuable source of stability and
resilience.

Intervention Plan:

Intervention plan was designed to help the client to resolve problem he is facing andto aid the
natural process of adjustment, to develop a positive self-concept and to save him, and to learn to
interact with others.

Short Term Goals

• By using supportive therapy build a level of trust with the client and create
supportiveenvironment that will facilitate the client to share his problems.  Active
listening, positive reinforcement, reassurance and unconditional acceptance tofacilitate
his sharing and catharsis.  Implement appropriate relaxation techniques to enable him
manage his stress, and toget relax in anxiety provoking situations and thoughts.  The
primary short-term goal is to help the patient reduce or eliminate cannabis use to
minimize the exacerbation of psychotic symptoms and facilitate recovery.  The focus is
on symptom management through the use of medication, therapy, and supportive
interventions to alleviate distressing psychotic symptoms such as hallucinations,
delusions, and disorganized thinking.  Encourage the patient to adhere to prescribed
 12

medication regimens to ensure the effectiveness of antipsychotic medications in

managing psychotic symptoms and reducing the risk of relapse.

• Teach the patient coping strategies to manage stress, anxiety, and other triggers
that may contribute to cannabis use or exacerbate psychotic symptoms. This may include
relaxation techniques, problem-solving skills, and mindfulness practices.  Assist the
patient in developing a routine that emphasizes self-care activities, such as maintaining a
healthy diet, regular exercise, sufficient sleep, and engaging in hobbies or activities that
promote relaxation and overall well-being.

Long Term Goals

• Continuation of short term goals.  Proper follow-up sessions with the client, to
revise short term goal, and to incorporate new skills and techniques to make the client
proficient.  Involve the patient's family members in the treatment process, providing
them with education about cannabis-induced psychosis and guidance on how to provide
supportive and understanding environments to aid the patient's recovery..

Therapies:

Rapport Building

The purpose of employing this technique was to establish a strong therapeutic alliance with the
client. By cultivating rapport, the client felt comfortable opening up about all of their concerns,
thereby improving their communication skills in a positive manner. Additionally, the aim was to
instill confidence in the client, which was achieved through active listening, expressed through
nodding and using encouraging words to facilitate the client's expression while demonstrating
genuine interest.

Psychoeducation

The psychologist provide the client with comprehensive information about his disorder, its
symptoms, potential triggers, and treatment options. This helps the client understand their
 13

condition, promotes self-awareness, and empowers them to actively participate in their own
management.

Relaxation Techniques

Deep Breathing as a relaxation exercise was demonstrated to the client as first aid which help in
the reduction of stress level and help in the reduction of symptoms severity level. The client was
explained with the benefits of this technique and its importance in the reduction of the depressive
symptoms he is experiencing. The client was instructed to sit on the chair with arms on the knees
and straight posture, close the eyes and think of any person place or thing which he loved the
most and let the body relax. After that he was instructed to take a long breath through nose and
hold it for few seconds and then release the breath slowly through mouth and repeat the
procedure.

Anger Management

This technique was used to manage excessive anger which may harm the client or person related
to him. This technique was applied on the client because he was having a complaint of excessive
aggression and difficulty in control. Some techniques were practiced and demonstrated to the
client to control excessive aggression such as he was directed to write possible ways to express
anger in an acceptable way. And these were practiced daily to help him apply when he needs it.
This was involve exploring triggers, identifying early warning signs of anger, and teaching
strategies for anger expression and coping. The goal was to help the client recognize and manage
their anger in a constructive and healthy manner.

Medical Adherence

The psychologist emphasize the importance of medication adherence and work collaboratively
with the client to address any barriers or concerns they may have. This involves discussing the
benefits and potential side effects of medication, addressing misconceptions, and exploring
strategies to support consistent medication use. The psychologist also collaborate with the client's
psychiatrist or healthcare provider to monitor medication effectiveness and make necessary
adjustments

Post Management Assessment

 14

The table shows the pre and post management ratings of the client on his problematic behaviors.
The comparison is suggesting that the client had progressed a lot and his improvement rate is
15%.

Table 3: Showing Comparison of Pre and Post Management Rating of Client

Symptoms Pre Rating Post

Rating

Elevated mood 10 9

Racing thoughts 9 8

Over talkative 10 8

Religious grandiosity 10 9

Restless 9 7

Aggression 9 7

Total 57/60 48/60

Percentage Difference 95% 80%

Improvement 95-80=15%

Recommendations:

 Family therapy should be offered to the client's family to provide comprehensive

support.
 15

 Allocating a separate session room would ensure confidentiality and provide a more
comfortable space for the client to share personal information.
 16

Limitations:

 The absence of a distraction-free environment during sessions with the client created
disturbances and hindered the progress of therapy.
 Due to the unavailability of the client's family, the opportunity to cross-check
information and gain a comprehensive understanding of the situation was limited.
 The client lacked a designated private space to sit quietly and focus on the assigned
tasks given by the trainee psychologist.
 A separate session room was unavailable, which compromised the trainee clinical
psychologist's ability to maintain confidentiality.

16
 17

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental

disorders, text revision DSM-5-TR. (5th ed.). American Psychiatric Association American
Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th
ed.). Arlington, VA: American Psychiatric Publishing.

Johnson, S. L., Cuellar, A. K., Ruggero, C., Winett-Perlman, C., Goodnick, P., White, R., &
Miller, I. (2012). Life events as predictors of mania and depression in bipolar I disorder.
Journal of Abnormal Psychology, 121(3), 680–686.

Malkoff-Schwartz, S., Frank, E., Anderson, B., Sherrill, J. T., Siegel, L., Patterson, D.,
Kupfer, D. J. (1998). Stressful life events and social rhythm disruption in the onset of manic
and depressive bipolar episodes: A preliminary investigation. Archives of General Psychiatry,
55(8), 702–707.

Merikangas, K. R., Jin, R., He, J. P., Kessler, R. C., Lee, S., Sampson, N. A., Zarkov, Z.
(2011). Prevalence and correlates of bipolar spectrum disorder in the world mental health
survey

Whisman, Mark A., et al. “Longitudinal Association between Marital Dissatisfaction and
Alcohol Use Disorders in a Community Sample.” Journal of Family Psychology, vol.20, no.
1, 2006, pp. 164–167,

17
18

18