Why do some people get anxiety from cannabis?
Sometimes, a patient will tell me she is very reluctant to try medical cannabis, because a brownie gave her intense anxiety ten years ago.
In the same day, another patient will tell me cannabis, even in high amounts, has never made her anxious.
The cannabis gurus online (Leafly and other sites) sometimes weigh in on this topic, but aren’t helpful. They merely say “everyone is different, and everyone reacts differently to marijuana.” They do not explain why. So people are left in the dark, some people abandon cannabis altogether, and most dispensaries adopt a trial-and-error approach, which is not exactly reassuring.
I believe I know some of the reasons for the difference, and in this article, I will try to explain.
First of all, anxiety is not one thing. It is many things. There are numerous types of anxiety.
I can think of five or six right off the bat, but I am a psychiatrist, and this is my particular training. Any given person is likely only to ever feel only a couple different types as an adult. During our lifetime, we pass through almost every type of anxiety. Some of us get stuck on various types, and we carry that “fixation” into adulthood. We all may have felt separation anxiety at age 1, when our mothers passed us into the arms of a stranger. That type of anxiety is perhaps similar to what is known as a panic attack. Likewise, many of us felt the anxiety of “OCD” at eight years old, when we were obsessed with not stepping on cracks, so as to protect our mother’s back.
I will list at least five or six types of anxiety here, but there are more. And which types of anxiety you carry into adulthood, largely hinges on your personality structure.
Types of anxiety include:
1. Obsessive Anxiety. This is what we call worrying, ruminating, brooding. Much of what is referred to as “social anxiety” probably falls in this category. This type has a high overlap with depression and guilt, whereas #3 below, panic, does not. The fears of OCD, fears about contamination, leaving the stove on, fussiness over filling out forms correctly, these are all types of obsessive anxiety. So too, is worrying how you come across socially, or feeling excessive guilt about everyday troubles.
2. Compulsion Anxiety. (urges to pick skin, hair, etc.) This is the kind of anxiety that is also related to OCD, but can also stand on its own, without it. Included are such behaviors as repetitive hand washing, picking at hair or skin, swearing or cursing uncontrollably, blinking three times before throwing a baseball pitch. Some compulsions are not part of OCD, such as bulemia, for instance, which falls squarely in this category.
3. Hysterical/Psychosomatic Anxiety. This is the type of anxiety which Freud made a living off of… It is basically the opposite of OCD. It is a vague type of anxiety that doesn’t readily acknowledge itself. The person seems unaware. It often assumes an outward form by worrying about other people (projection). Sometimes it will take the form of a psychosomatic symptom, or show up as unexplained chronic fatigue or sexual problems.
4. Panic Attacks. This unique type also has little in common with OCD. As a psychiatrist, I know, with panic attacks, right off the bat, that the person is unlikely to have traits of OCD. Same reason people with OCD are almost never prescribed Xanax. But people with panic attacks often are. Panic attacks cause light-headedness, sweating, the thoughts to spiral out of control, a sense of impending doom, a pounding heart, and a vague feeling that things are you are “not real” or things are “not real”. Sometimes, there is a feeling that your body no longer belongs to you, or that your mind and body are disconnected.
6. Hyper-vigilance (PTSD) Anxiety. This is what we call chronic stress. It is a form of anxiety caused by trauma, and its cause is adrenaline surging through the body 24/7 (at times when it should be turned-off). It can be caused by combat, emotional trauma, physical abuse, rape, molestation, or in a milder form through ongoing perceived threats from others. This is a biologically-driven type of anxiety, accompanied by guarded thoughts, preoccupied by external danger. It gives nightmares, and it makes a person easily startled.
6. Annihilation Anxiety. This is a subtle but profound anxiety that is uniquely experienced by those with schizophrenia, or other psychotic persons. It can be described thus: you feel the entire world may disappear at a moment’s notice. Or, others can steal your thoughts, see into your soul, dissolve your identity, or lay claim to your soul.
So… there’s just a few types.
There are many more, but that’s enough for now.
You may be able to imagine feeling all of these types of anxiety, even the last one. We probably all felt that last type of anxiety when we were first born as a helpless infant. (Whereas, a person with schizophrenia may experience it occasionally throughout their life.)
However, no matter how much you can imagine them all, chances are, if you have anxiety as an adult, you’ve struggled with only one or two types in your lifetime.
If you are a person with obsessive compulsive traits, and you like to count numbers, stay organized, bite your nails, or pick your skin, you’ve likely only experienced #1/2, or variations of the two. Whereas, if your personality is more flexible, (not obsessive) and if you lose track of your keys quite a bit, or often let something slip out which you wish you hadn’t said, then you have a less rigid personality structure. You’ve perhaps experienced #3/4, but probably not #1/2.
Again, different personalities only experience certain types of anxiety. If you are prone to frequent bouts of power-struggles, anger, or rage, it is unlikely you struggle with types #3/4. Someone with #3 panic attack anxiety, is almost never angry, for interesting reasons I won’t go into here. Suffice to say that if you’ve ever had a panic attack, you’re almost immune to bouts of rage. People with #4 can definitely be angry, but it won’t show itself as typical huffing and puffing. It’s likely to be a more subtle, hidden, or masked type of anger.
But enough about personality.
My main topic here is cannabis, and why some people get bad anxiety reactions to it, whereas other people say it cures their anxiety.
When people say they got really anxious from a pot brownie, whether they realize it or not, they’re almost always talking about anxiety #3. Maybe, #4, but almost always it’s #3. They are almost never talking about types #1/2.
Ordinary cannabis (high THC varieties) never cause types #1/2. In fact, THC greatly reduces obsessional anxiety, social anxiety, ruminations, etc. It can also help with #2. I have a patient who picks his eyebrows compulsively, and has been on SSRI’s for years. After starting cannabis, he has had greater reduction in his behavior than he did from taking prozac for years!
But ordinary cannabis cannot treat #3/ panic attacks. In fact, high THC varieties make it worse.
However, special types of marijuana can help #3. If you take high dose cannabidiol (CBD), or CBD rich varieties of marijuana, you can treat #3 successfully. Marijuana plants that contain CBD (instead of THC) are rare, but they are becoming more common in dispensaries. Hawaii’s first dispensary on O’ahu, Aloha Green Holdings, will likely sell “Hurkle”, a CBD dominant variety. In Portland, Oregon, where I visited, I was able to find many CBD rich types, such as “Frank’s Gift”, “Charlottes Web/Blueberry”, and much more. These varieties are incredibly useful for #3.
For example, I have one particular patient with vague “depersonalization” anxiety, or a variation of anxiety type #3, who occasionally feels as if her body is not her own body… This patient never used LSD, but sometimes people who used LSD too much ends up with type #3, due to the long term effects of LSD on the brain. This particular patient did not use LSD but still has #3 pretty bad. Her heart beats fast, and she feels “weird”. She takes CBD now, and says it works just as well as Xanax! Usually, people with anxiety type #3 are given Xanax or Valium- these are highly addicting medicines.
If you have ever had a panic attack in your life, and if you are trying medical marijuana, you should avoid high THC varieties. Problem is, that’s most of the cannabis you find in dispensaries. Instead, you should stick to CBD dominant strains like “Harlequin” or “Charlotte’s Web.” Such strains have both THC and CBD, or almost entirely CBD. Sometimes people need to experiment with either no THC, or just a little THC together with the CBD, since personality is a spectrum and the above categories do have some overlap.
Again, if you’ve never had a panic attack in your life, but you do have strong anxiety of type #1/2 then THC will be your friend. There may still may be reasons to add CBD, (for instance, to reduce the distracting effects of THC) but THC will never be harmful.
In fact, if you are strongly type #1/2 too much CBD by itself may make your OCD anxiety worse… how this happens isn’t known, but I’ll speculate. CBD has antipsychotic properties, so it’s a kind of anti-psychedelic. THC is the opposite, a mild psychedelic. (A mind opener). Whereas CBD is a mind-closer; it glues the mind back together. THC will loosen up your personality, making you more open to perception, the outside world, in other words, make you less like a worried professor, and more like a child. Whereas CBD has the opposite effect. It will tie up the mind together and oppose the psychedelic effects of THC. I like to think of CBD as mind-glue. This is the same reason some people claim that CBD has an “alerting” or focusing/organizing effect.
This makes sense to me, as a doctor who prescribes antipsychotics quite frequently. Sometimes, antipsychotics will actually cause OCD symptoms. Clozapine, an antipsychotic given for schizophrenia, will usually cause OCD symptoms at high doses. This is because OCD and psychosis are opposite mental states. Anxiety types #1/2 are furthest from psychosis, whereas types #3/4 are “closer” to psychosis, so to speak. If people with type #1/2 were to take LSD, they may not receive any harm, but if persons with type #3/4 take LSD, they could be irreparably harmed, and left with a panic disorder, for instance.
I am often asked what type of marijuana helps autism.
Since autism is so very similar to anxiety types #1/2, then THC works well for autism.
Some people give CBD oil for autism, because they think that CBD is for children, since it doesn’t produce a high. This is unfortunate… If autism is what’s being treated, whether aggressiveness, anger, or obsessive thinking, with compulsive (#2) rituals behaviors, then THC is the answer for the rigidity. Not CBD! Some CBD may be useful for gut-inflammation and other problems with autism, but the THC is what will help with the rituals and obsessive symptoms. THC will reduce anxiety #1/2 in an autistic person, rendering them more docile, friendly, less controlling/insistent, and even perhaps slightly empathic.
It’s a shame that CBD is thought of as the “safe” cannabinoid for kids, when actually, CBD has a potential to raise drug levels of seizure drugs, and other pharmaceuticals. In reality there is no perfectly “safe” medicine and every medicine should be chosen with the help of a highly knowledgable clinician.
That’s enough about types 1/2/3/4.
A brief word on type #5:
Those with anxiety type #5 have usually experienced trauma, and whether THC will help them, or make them worse, depends on their personality structure, as I have stated above. There are people with PTSD who have OCD personalities, and there are people with PTSD who have the opposite personality type, which is called “dissociative” (loose, not rigid). This latter group should be wary of taking too much THC.
Personality is difficult to detect, when it’s subtle. It can be detected if you have training in it- but not all psychiatrists do. Some stage magicians are better than psychiatrists. They can pick out personalities, almost as well as a trained psychoanalyst. Skilled magicians and hypnotists are usually able to determine if a person is rigid, or suggestible, or dissociative, just by interacting with the person for a number of minutes.
A brief word on #6.
Psychotic persons with anxiety type #5 should probably avoid THC. Again, CBD may actually help, since it has antipsychotic properties.
In summary, we need a more sophisticated classification of anxiety.
Anxiety is not one thing. It is half a dozen things, if not more.
If we do not get more sophisticated, we leave ourselves open to criticism from the anti-cannabis crowd, who thinks that marijuana is unpredictable, dangerous, and doesn’t treat anxiety the way some claim it does.
Cannabis is very predictable, if we have knowledge of the mind, and of personality. This understanding may go a long way to helping people feel a sense of self mastery and control over their anxiety as well as a deeper respect for their chosen natural medicine.
Dr. Cook
