By Samira Hussein

Annie is an eighteen year old girl attending university for the very first time. For as long as she could remember, she never had any issues with her appearance other than brief, superficial concerns about a new hairstyle  or trying on a different outfit in the changing room. It wasn’t until recently, entering this completely new environment, that she began to become concerned with her looks and the way she presents herself to other people. One of her major worries is that her face is asymmetrical, and that one side of her jaw appears larger than the other. As well, she is extremely concerned that she will soon be unable to fit into her clothing, despite maintaining her weight.

These body image concerns begin to overwhelm Annie. To relieve some of her worries, she begins to uncontrollably check every reflective surface she passes by, including shop windows and bathroom mirrors, as well as taking numerous photos with her smartphone. Some days, she finds it difficult to gather the courage to leave her dorm room and attend class or hang out with her friends because of her appearance concerns. She is intensely worried about what other people might think of how she looks, and unfortunately finds herself slowly withdrawing from the new friendships she’d acquired in this new environment. Annie feels very alone and isolated due to this, so sometimes she’ll have a couple of drinks to pass the time and help her calm down. At first, it’s only a few glasses of wine before bed to help relax after missing an important class, or when she fears her friends hate her for missing another outing, but soon she finds herself needing more to get that same effect. Unfortunately, Annie ends up failing two classes in her first semester, much to the disappointment of her parents. Despite trying to cut back on the amount of alcohol she drinks, Annie finds it extremely difficult.

What is Body Dysmorphia?

The intense stress Annie experiences as a result of her unhealthy obsession with her body image is consistent with a psychological condition called Body Dysmorphia, or Body Dysmorphic Disorder (BDD). This is a disorder where people tend to become extremely focused on a perceived defect of their appearance  (such as weight gain, whether it is there or not) that causes the person extreme feelings of distress. This distress often interferes with their ability to function on a daily basis, such as in their ability to keep up with their personal relationships, schoolwork, and even work obligations (Grant et al., 2008). BDD can be characterized by:

• Obsessive thoughts that disrupt daily
• Making constant comparisons with others
• Extremely frequent grooming behaviours (such as  skin picking, pulling hair, applying makeup, etc.)
• Camouflaging or hiding the area of insecurity (e.g., wearing baggy clothes)
• Behaviours that are repetitive or even ritualistic in order to reduce distress (this includes searching for constant reassurance from others, body checking in reflective surfaces, taking photos, and more)

Body dysmorphia can interfere greatly with one’s functioning in everyday life, as misperceptions about their appearance can often occupy their attention for extended periods of time (Buhlmann et al., 2008). Social situations may be extremely difficult to attend, as individuals with BDD are prone to feelings of anxiety, shame, discomfort, and embarrassment due to their concerns (Cunningham et al., 2017). The difficulties associated with BDD can lead to a variety of poor health outcomes that require greater attention, including but not limited to potential eating disorders as well as issues with substance use.

Trends to Consider

BDD tends to arise within young adults and adolescents, and due to the stigma and secretive nature of this disorder, it most commonly can become chronic in duration, thus increasing the potential for poor health outcomes (Veale et al., 1996; as cited in Buhlmann et al., 2008; Grant et al., 2008). Many individuals do not receive treatment until the disorder has significantly progressed in severity due to stigma and barriers, and taking into account mental health issues that may arise over the course of one’s life, symptoms and treatment will vary from person to person (Schneider et al., 2019). A lower quality of life, increased risk of suicide, and substance use in particular are heavily implicated in trends associated with BDD. Recent research suggests some individuals may misuse substances to help cope with the negative emotions and feelings that come with BDD, especially among university students who may use drugs for social engagements (Cunningham et al., 2017). These trends are extremely alarming when considering the potentially severe impact this disorder can have over the course of a lifetime, highlighting an increasingly important area for further research.

So, how is Body Dysmorphia and Drug Use Related?

            Many individuals living with BDD understandably struggle to manage their intense feelings of distress even with their compulsive and ritualistic behaviours, and in recent years, researchers have noticed a link between BDD and substance use. Recreational drug use is often adopted by people struggling with extreme distress as a result of BDD in order to cope, with the most common substances being alcohol and cannabis (Gunstad & Phillips, 2003; Phillips et al., 2005; as cited in Kelly et al., 2017; Grant et al., 2019; Grant et al., 2008). The amount of individuals both struggling with a substance use disorder as well as BDD is considered extremely high. Dealing with both disorders at the same time can further exacerbate issues with day-to-day functioning, suicidality, and overall well being (Phillips, 2007; as cited in Kelly et al., 2017; Grant et al., 2005). This relationship has been of particular concern following a 2008 study by Grant et al., in which approximately half of a group of young adults adolescents with body dysmorphia reported that their symptoms relating to BDD were partly responsible for their drug use in the first place. Despite many individuals reporting using substances as a coping mechanism to deal with their emotions, research has suggested that those with substance use disorders tend to have extreme symptoms related to BDD, such as more hospitalizations and poorer overall functioning (Grant et al., 2008). Additional research has found links between poor body image and dangerous drinking specifically in the undergraduate university population, and that main reasons for drinking may be to cope with concerns about one’s body image concerns in public social settings (Cunnningham et al., 2017; Kellelly et al., 2017). Despite numerous studies highlighting the relationship between substance use and BDD, it is not yet entirely known why this specific relationship occurs. Instead, the focus is primarily on treating individuals with both of these disorders. Co-occurring drug use with body dysmorphia is complicated, and due to shame and embarrassment, some individuals may be reluctant to tell their clinician that they have BDD when entering treatment for a substance use issue. Failure to treat one or the other can result in poor health outcomes, especially if BDD is not addressed as a potential underlying influence for the substance use (Grant et al., 2008). More research is needed to fully understand the complex relationship between the two disorders and how they can negatively impact one’s quality of life and treatment outcomes.

Minority Groups at Risk: LGBTQ+ 

            A particular group has been highlighted in numerous research studies to be particularly vulnerable to issues with both substance use and BDD. Previous research examining the relationship between body dysmorphic disorder and sexual and gender minorities suggests that individuals identifying as gay, lesbian, bisexual, and/or transgender are at risk for intense concerns regarding their body image and appearance. The Minority Stress model (Meyer, 1995; as cited in Oshana et al., 2020) suggests individuals that are part of the LGBTQ+ community are exposed to stress constantly, and this stress leads to negative expectations for interacting with other people. In order to minimize the amount of potential poor, a person might try to hide any potential indicators of their minority status and focus intently on the way they present themselves to others, including through their appearance and behaviour (Meyer, 2003; as cited in Oshana et al., 2020). Minority stressors that are unique to individuals of minority status includes:

• Fear of rejection
• Concealment of sexual orientation
• Prejudice and discrimination
• Stigma
• Violence
• Internalized homophobia

Exposure to stressors like these tend to be chronic for many individuals, which unfortunately can increase one’s risk for developing mental health issues (Parker & Harriger, 2020). Body dysmorphia research has noted increased rates of body dissatisfaction in male college students who are gay or bisexual compared to heterosexual men, and further research has noticed that university students who reported symptoms consistent with BDD had a tendency to also identify as trans or gender queer, noting the added stress in this population on top of the challenges associated with young adulthood possibly has a major impact in the development of body image issues (Oshana et al., 2020; Grant et al., 2019). This is an extremely underdeveloped area of research, however. A growing focus on the relationship between substance use and body dysmorphia might suggest that sexual and gender minorities may particularly be at risk for substance use issues. Additional research on unique health outcomes and effective methods of treatment (especially those that are sensitive to the unique experiences of sexual/gender minorities) thus must be prioritized.

What can we do to help?

            While this is a relatively new field of research, there is enough existing research on treating body dysmorphic disorder and substance use disorders separately to suggest that we’re heading in the right direction. In the case of Annie, entering college is an extremely formative period that can increase one’s stress greatly. Similar to many other individuals with co-occuring issues using drugs while struggling deeply with their body image, body dysmorphia has consistently been found to be the initial mental health concern that leads to substance use as a coping mechanism. People in Annie’s situation will be glad to know that cognitive behavioural therapy combined with psychoeducation is considered to be an effective mode of treatment for both body dysmorphic disorder and substance use disorders (Buhlmann et al., 2008; McHugh, Hearon, & Otto, 2010; as cited in Cunningham et al., 2017). However, due to the complexity of both disorders and potential complications of treating one and ignoring the other, it is extremely important for clinicians to ensure they adequately screen individuals for BDD as a co-occurring condition. Populations that require this extra level of care include young adults as well as marginalized individuals (including sexual and gender minorities, and perhaps even ethnic minorities as well). Future research on the impact of minority stress and treatment is needed, especially on how to potentially adapt existing forms of treatment to become more sensitive to the unique experiences of individuals from minority groups.

Resources

Both body dysmorphia and substance use disorders run into the issue of stigma, and one of the major barriers to treatment for individuals struggling with either or both disorders is shame and secrecy. It is important to remember that both body dysmorphic disorder and substance use issues are not taboo, and honest, public dialogue is the best way to ensure that anyone struggling no longer feels alone.

If you or anyone you know is having thoughts of suicide, please contact:

• Canada Suicide Prevention Service at 1-833-456-4566 (24/7)
• Kids Help Phone at 1-800-668-6868
• Hope for Wellness at 1-855-242-3310

References

Ahmedani B. K. (2011). Mental Health Stigma: Society, Individuals, and the Profession. Journal of social work values and ethics, 8(2), 41–416.

Buhlmann, U., Reese, H. E.eese, Renaud, S., & Wilhelm, S. (2008). Clinical considerations of treatment of body dysmorphic disorder with cognitive-behavioural therapy. Body Image, 5, 39-49.

Cunningham, M., Stapinski, L., Griffiths, S., & Baille, A. (2017). Dysmorphic Appearance Concern and Hazardous Alcohol Use in University Students: The Mediating Role of Alcohol Expectancies. Australian Psychologist, 52(6), 6), 424-432.

Grant, J. E., Lust, K., & Chamberlain, S. R. (2019). Body Dysmorphic Disorder and Its relationship to Sexuality, Impulsivity, and Addiction. Psychiatry Research, 273, 260-265.

Grant, J. E., Menard, W., Pagano, M. E., Fay, C., C., & Phillips, K. A. (2008). Substance Use Disorders With Body Dysmorphic Disorder. Journal of Clinical Psychiatry, 66(3), , 309-405.

Kelly, M. M., Simmons, R., Wang, S., Kraus, S., Donahue, J., & Phillips, K. A. (2017). Motives to drink alcohol among individuals with body dysmorphic disorder. Journal of Obsessive-Compulsive and Related Disorders, 12, 52-57.

Oshana, A., Klimek, P., & Blashill, A. J. (2020). Minority Stress and body dysmorphic disorder symptoms among sexual minority adolescents and adult men. Body Image, 34, 167-174.

Pagano, M. E., Phillips, K. A., Stout, R. L., Menard, W., & Piliavin, J. A. (2007). Impact of Helping Behaviors on the Course of Substance-Use Disorders in Individuals with Body Dysmorphic Disorder. Journal of Studies on Alcohol and Drugs, 68, 291-295.

Parker, L. L. & Harriger, J. A. (2020). Eating disorders and disordered eating behaviors in the LGBT population:: a review of the literature. Journal of Eating Disorders, 8(51).

Ruffolo, J. S., Phillips, K. A., Menard, W., W., Fay, C., & Weisberg, R. B. (2005). Comorbid. Ity of body dysmorphic disorder and eating disorders: Severity of psychopathology and body image disturbance. International Journal of Eating Disorders, 39(1)1), 11-19.

Schneider, S. C., Turner, C. M., Storch, E. A., & Hudson, J. L. (2019). Body dysmorphic disorder symptoms and quality of life: The role of clinical and demographic variables. Journal of Obsessive-Compulsive and Related Disorders, 21, 1-5.

Zimmerman, M. &  Mattia, J. I. (1998). Body dysmorphic disorder in psychiatric outpatients: Recognition, prevalence, comorbidity, demographic, and clinical correlates. Comprehensive Psychiatry, 39(5), 265-270.

By Tara Raessi

            During Pride month, many of us celebrate how far LGBTQ2S+ communities have come in advocating for the rights they so long deserved. For plenty, though, it is a reminder of how much work we have ahead of us. Various significant changes occurred only recently, such as Canada’s ban on conversion therapy less than a year ago (Government of Canada, 2021).  Even with historical events such as the Diagnostic and Statistical Manual removing homosexuality as a paraphilia, actual changes within our societies have been slow (Drescher, 2015). The reality is that populations have come to a bare-minimal acceptance of LGBTQ2S+ communities and have only just started to accommodate such minority groups. For example, we know little regarding the effects of gender minority stressors on substance use for transgender populations, a discussion that has only risen in academic discussion in the late 21st century. 

What are Gender Minority Stressors?

            In brief, gender minority stressors are distressing stimuli experienced by persons with gender identities that are commonly victimized (Tan et al., 2020). These stressors exist because social norms on gender identity (e.g., the ideology of only male and female genders, the nuclear family, etc.) do not reflect the culture of these less-common gender identities (Tan et al., 2020). As a result of these conflicting interests, “other” gender identities are perceived negatively, which creates adverse experiences for those identifying with those outcasted genders (Tan et al., 2020). One of the biggest social norms pertaining to gender identity involves cisnormativity, which refers to the belief that a “normal” gender identity is one whose gender identity reflects their biological sex at birth (Tan et al., 2020).

Substance Use

There are mixed findings on whether exposure to gender minority stressors is associated with a higher probability of alcohol use. Some studies have identified an association between increased exposure to gender minority stressors and alcohol use (Katz-Wise et al., 2021; Watson et al., 2019). Specifically, family functioning and social support positively influenced this relationship, though Watson et al. (2019) did not identify any factors to protect against problematic drinking for transgender youth (Katz-Wise, 2021). Internalized homophobia and enacted stigma were negatively influential on alcohol use for gender minority adolescents (Katz-Wise et al., 2021; Watson et al., 2019). Others have identified a correlation only with transgender men (Gonzalez et al., 2017). This discrepancy may be due to the limitations commonly found in transgender research, such as small sample size, predominantly white participants, geographic constraints, self-reported data, non-random sampling, and the awareness of confounding variables such as the impact of hormone treatment. Additionally, this discrepancy may still exist because of the gap in the literature. For example, in 2018, Kidd et al. were unable to find any research on gender minority youth and substance use. 

Similar to alcohol, there were various findings on cannabis, tobacco, and illicit drug use. Katz-wise (2021) found that gender minority stressors did not significantly influence cannabis use. Another study found an association between gender minority stressors and cannabis use only in transgender women, which was further exacerbated by young age and lower annual income (Gonzalez et al., 2017). For gender minority adolescents, there was no significant association between gender minority stressors and tobacco use (Katz-wise, 2021). There was no primary literature evaluating the relationship between tobacco use with transgender populations. Gender minority stressors were not found to be a significant predictor of illicit drug use for transgender populations (Gonzalez et al., 2017); yet, Reisner et al. (2014) found an association between illicit drug use and exposure to gender minority stressors for transgender women. Reisner et al. (2014) additionally found that this association was strengthened when financial hardship was involved. There is insufficient literature on these associations and limitations in the existing research.

Overall, there appears to be a lack of research in understanding how gender minority stressors affect transgender populations’ substance use. While such research is increasingly being developed, such as at TMU’s own Clinical Addictions Research Equity Lab, there are many barriers to studying transgender populations. There seems to be difficulty in conducting random sampling with replacement, which in turn causes disproportionate sample graphics. While this research hurdle may never be overcome, we can hope that with continued advocacy more transgender persons will be able to safely and confidently participate in research studies.

What Can You Do?

There are many ways to act as an ally and support transgender communities. Here are some actions to consider:

• Advocate for nonbinary accommodations at your workplace, educational institution, or local businesses. This can include: requesting the implementation of a non-gendered bathroom and/or bathrooms that explicitly associate their bathrooms with gender identity, not biological sex; requesting a zero-tolerance policy for gender discrimination at work or school; encouraging the identification of pronouns during introductions, and/or; requesting for workshops that educate about transgender experiences and ways to be a better ally in the classroom/workplace.
• Support transgender organizations and events. This may include volunteering at a local organization, attending fundraising or advocacy events, and requesting that organizations/events be gender-inclusive.
• Listen! Do not assume that all transgender experiences are the same, or that all transgender persons express their gender identities the same. Ask persons you recently met for their preferred pronouns, be mindful and open to discussing transgender experiences, and place yourself in a position to learn.

Resources 

If you identify as LGBTQ2S+ and would like support for substance use, consider reaching out to the following organizations:

Gender Identity Clinic CAMH

Rainbow Services CAMH

Sherbourne Health

The 519 Programs: LGBTQ2S Communities

References

Drescher, J. (2015). Out of DSM: Depathologizing homosexuality. Behaviour Science, 5(4), 565-575. https://doi.org/10.3390%2Fbs5040565 

Government of Canada. (2021, November 29). Proposed changes to Canada’s Criminal Code relating to conversion therapy. https://www.justice.gc.ca/eng/csj-sjc/pl/ct-tc/index.html 

Katz-Wise, S. L., Sarda, V., Austin, S. B., & Harris, S. K. Longitudinal effects of gender minority stressors on substance use and related risk and protective factors among gender minority adolescents. PLoS ONE 16(6), e0250500. https://doi.org/10.1371/journal.pone.0250500 

Kidd, J. D., Jackman, K. B., Wolff, M., Veldhuis, C. B., & Hughes, T. L. (2018). Risk and protective factors for substance use among sexual and gender minority youth: A scoping review. Current Addiction Reports, 5, 158-173. https://doi.org/10.1007/s40429-018-0196-9 

Reisner, S. L., Gamarel, K. E., Nemoto, T., & Operario, D. (2014). Dyadic effects of gender minority stressors in substance use behaviours among transgender women and their non-transgender male partners. Psychology of Sexual Orientation and Gender Diversity, 1(1), 63-71. https://doi.org/10.1037%2F0000013 

Tan, K. K. H., Treharne, G. J., Ellis, S. J., Schmidt, J. M., & Veale, J. F. (2020) Gender minority stress: A critical review. Journal of Homosexuality, 67(1), 1471-1489. https://doi.org/10.1080/00918369.2019.1591789 

Watson, R. J., Veale, J. F., Gordon, A. R., Clark, B. A., & Saewyc, E. M. (2019). Risk and protective factors for transgender youths’ substance use. Preventive Medicine Reports, 15, 100905. https://doi.org/10.1016%2Fj.pmedr.2019.100905 

By Hannah Rasiuk

Image description: A cannabis retailer employee weighs cannabis flowers on a scale. Image retrieved from Unsplash (2016).  

Amidst the ongoing closures of local businesses during COVID-19, many residents have noticed an explosion of new cannabis shops opening in Toronto neighbourhoods.¹ As plans have been revealed to license 80 new Ontario cannabis retailers per month, the drug is becoming increasingly accessible.¹ Given that cannabis has become the most widely used mind-altering drug among North Americans,² Torontonians likely make choices about personal cannabis use on a regular basis. However, common misconceptions about cannabis may create difficulty in making informed decisions about recreational use. 

Cannabis is often thought of as a harmless substance and tends to be used by individuals to help with medical issues, without concern for its addictiveness.³ In reality, approximately 1 in 3 people who use the drug develop issues with their use, with 1 in 11 people developing the addiction, cannabis use disorder.⁴ Alongside being addictive, cannabis use may actually pose major risks to personal health.⁵ For example, research studies have been finding a connection between cannabis use and psychosis. An important part of understanding this relationship involves answering the question: does cannabis use actually cause psychosis to develop. The following discussion will unpack what psychosis is, as well as the research on this relationship in order to figure out if cannabis use could realistically cause psychosis, and how this might occur.

What is psychosis? 

Psychosis is a term used to describe personal problems and disruptions in mental functioning that results in people having difficulty staying in touch with reality. People experiencing psychosis have distressing changes in their normal beliefs, thoughts, behaviours, and ways of perceiving the world around them. The term can be used to describe the broad range of symptoms associated with psychosis, as well as to mental diagnoses that involve psychosis. For instance, schizophrenia is a well known psychotic disorder.^6,7

Infographic by Hannah Rasiuk, template from CANVA is licensed under a CC BY-NC-ND 2.0., information retrieved from Schizophrenia Society of Canada (n.d.).

What are the symptoms of psychosis? 

Psychosis can look different among people who are experiencing it and can develop quickly, or gradually over time. The complex symptoms that individuals with psychosis may experience are listed below:

• Hallucinations, which may involve perceiving sounds or visions that are not actually occurring
• A loss of the sense that one’s experiences are, in fact, their own personal experiences 
• Difficulty beginning tasks 
• Reduced range of emotions and speech
• Disorganized thoughts, speech, or behaviour (this could include issues in completing daily tasks, or fast and confusing changes in subject matter when speaking). 
• Decreases in motivation 
• Spending more time alone and neglecting social relationships
• Issues with developing original ideas and thoughts
• Delusions, which involve strongly held beliefs that may be bizarre or unrealistic.^6,7

Can psychosis be caught early on? 

Although psychosis causes widespread negative effects on daily functioning, health, and well-being, it is a treatable condition.⁵ Treatments for psychosis commonly involve the use of medication, as well as psychotherapy. Antipsychotics are the main medication used to manage psychotic symptoms, and prevent symptoms in the future. Psychotherapy is useful for improving daily functioning and managing living with psychosis. Since psychosis is more easily treated when caught early on in its development,⁷ these symptoms may be important to look out for. Some early warning signs for the development of psychosis include:

• Difficulty in completing normal self-care and hygiene practices
• Decline in performance at work or school
• Difficulty communicating with others
• Adopting new ideas that may seem bizarre or intense
• New issues in critical thinking and concentration 
• Feeling suspicious of others
• Spending an atypical amount of time by oneself
• Trouble separating fantasy from reality.⁹ 

Infographic by Hannah Rasiuk, template from CANVA is licensed under a CC BY-NC-ND 2.0., information retrieved from CAMH (n.d.a).

What has research shown about the associations between cannabis use and psychosis? 

The development of psychotic disorders is complex. There are many factors that may cause psychosis, including imbalances of chemicals in the brain, as well as stressful life events. If drug use does play a role in its development, it can only partially explain its cause.⁷ 

Researchers believe that cannabis use may lead to psychosis by negatively affecting processes occurring in the brain. THC, also known as tetrahydrocannabinol, is the main ingredient in cannabis that creates changes in the brain that produce the ‘high’ feeling associated with use.¹⁰ Research suggests that THC interacts with chemicals in the brain that interrupt the brain’s ability to function normally. THC has effects on certain areas of the brain’s ‘reward circuit’, and affects the functioning of parts of the brain associated with critical thinking, mood, and meeting goals.¹¹ These changes in the brain may be reflected by the issues in thinking, attention, or memory that individuals often experience shortly after using cannabis. Studies have also shown that people with psychosis also have similar abnormalities and issues in these areas of the brain, which contributes to their psychotic symptoms. Given this overlap, researchers suggest that these disruptions in the brain caused by THC could potentially contribute to the development of psychosis.^11,12 

Research that focuses on individuals experiencing psychosis highlights how cannabis use may be linked to psychosis. Some of these findings include:

• Psychosis patients who use cannabis have been found to develop psychosis at younger ages. Cannabis users in one study were found to have developed psychosis 6 years earlier than non-users, on average.¹³ 
• Cannabis use has been found to cause ‘acute’ episodes of psychosis. An acute episode of psychosis happens when psychosis-like symptoms develop immediately after using cannabis. These symptoms may extend beyond the time that the individual is intoxicated and may come before a full psychotic episode.⁵
• Very few individuals who have already experienced psychosis report that they started using cannabis after their psychosis began.¹⁴ 
• Cannabis is the most commonly used mind-altering drug among individuals with schizophrenia. Within a study of patients with schizophrenia, 25% of patients had also received cannabis use disorder diagnoses.¹⁵
•  Some studies have shown that psychosis patients using cannabis are readmitted to hospitals more often than those who do not use the drug.¹⁶ 
• 37% of psychosis patients in a study shared with researchers that their first psychotic symptoms began while intoxicated from cannabis.¹⁷ 

Who might be vulnerable to developing psychosis after using cannabis? 

Certain individuals are more likely to develop psychosis when using cannabis than others. The age at which individuals begin to use cannabis, as well as a family history of psychosis have been shown to be particularly important in the relationship between cannabis use and psychosis. 

Did you begin smoking at a younger age?

Studies have demonstrated that participants who had used cannabis during teenage years had more psychotic symptoms, and were more likely to have schizophrenia later on in life.⁵ These results suggest that the teen years are an important and sensitive period of time for the brain’s development, and that cannabis use may negatively affect this development. For instance, a sample of psychosis patients who began using cannabis prior to the age of 16 developed psychosis at earlier ages than those who began using the drug after the age of 15.¹³ This highlights that using cannabis during adolescence, especially during early teenage years, may be particularly connected to the development of psychosis later on.

Do you have a family history of psychosis? 

Generally, individuals with a family history of psychosis are more likely to develop psychosis themselves.⁷ However, research suggests that cannabis use may uniquely increase the risk for developing psychosis among people with these genetic sensitivities.⁵ One study found that patients who were experiencing acute episodes of psychosis who had recently been using cannabis were 10 times more likely to report having a family history of psychosis, compared to patients who had not recently used cannabis.¹⁸ Among psychosis patients who use cannabis, it is common that family members who have experienced psychosis also use cannabis.¹⁹ 

Other studies have identified that certain genes that are inherited from parents may uniquely contribute to the development of psychotic symptoms after using cannabis. Researchers have found that people who have specific variations of 2 genes, called AKt1 and COMT, have a greater likelihood of experiencing psychosis-like symptoms after using cannabis, as well as developing psychosis later on.^5,19 These findings suggest that certain factors that are inherited from parents may allow some people to become particularly likely to develop psychosis after using cannabis. 

How might patterns of personal cannabis use increase the likelihood of developing psychosis? 

Certain patterns of cannabis use have been linked to the development of psychosis. Some relevant factors related to personal patterns include the frequency of cannabis use, as well as the strength, or potency of the cannabis used. 

Frequency of cannabis use

Many research studies have demonstrated that individuals who use cannabis on a daily basis have an increased likelihood of developing psychosis, including acute episodes of psychosis, compared to non-daily users.^20,5 Researchers in one study found that patients experiencing their first episode of psychosis tended to smoke on a daily basis, smoke more frequently, and for longer periods of time.¹³ Another set of researchers who studied individuals over the course of 25 years also found that daily use was associated with up to 3.3 times more likely to develop psychosis compared to non-users.²¹ These results suggest that daily cannabis use over time may result in an individual being especially vulnerable to developing psychosis.

Potency of cannabis used 

High potency cannabis has higher amounts of THC.⁵ This means that higher potency cannabis is able to give users a more intense ‘high’ feeling after consuming smaller amounts, compared to low potency cannabis. High potency cannabis is also becoming more widely available at legal cannabis stores, with a 17% THC content considered to be ‘strong’ among Ontario cannabis retailers.^22,23 Since cannabis retailers may not share information about the potency of their cannabis products, a guideline for this information is provided below:

Infographic by Hannah Rasiuk, template from CANVA is licensed under a CC BY-NC-ND 2.0., information retrieved from Government of Canada (n.d.b).

Numerous studies have found associations between higher potency cannabis and increased rates of psychosis.²² For instance, individuals experiencing their first episode of psychosis were found to have smoked higher potency cannabis at increased rates. The researchers in this study also found that potency was a factor that individually contributed to earlier onsets of psychosis among those who were studied.¹³ 

Image description: Close-up shot of various types of higher-potency cannabis extracts displayed on a metal spatula. Image retrieved from Pixabay (2018).

How sure can we be about these findings?

There are some limitations to this research that make it unreasonable to conclude that there is a cause-and-effect relationship between cannabis use and psychosis. The research does suggest that cannabis use is a relevant factor among people with psychosis. However, it is unclear whether the people in these studies would have developed their psychosis anyway, without the use of cannabis. Similarly, not everyone who uses high potency cannabis on a daily basis will develop psychosis. It could also be possible that there are other undiscussed factors that allow certain people to be more at risk for both using cannabis, and for developing psychosis. It might be more reasonable to remain cautious in believing that cannabis use causes psychosis, and that it might just partially contribute to its development.²¹

How might these research findings be applied to everyday life?

Overall, these research findings connecting cannabis use to psychosis suggest that its reputation for being harmless may be unrealistic². Evidence points to the idea that using high potency cannabis on a daily basis could contribute to the development of psychosis.^5,13 If individuals have used cannabis since adolescence, and/or have a family history of psychosis, they may be especially vulnerable to developing psychotic symptoms. If the findings in these research studies were able to determine a cause-and-effect relationship between cannabis use and psychosis, they could be applied to daily life by changing patterns of personal cannabis use. In this case, people currently using cannabis should consider using cannabis with lower potencies, and avoid using it on a daily basis. 

Cannabis use disorder may be a barrier for those who are motivated to change these patterns of use². Similarly to psychosis, cannabis use disorder is a treatable condition. Specifically, there is evidence that some psychotherapy options may be helpful for the treatment of cannabis use disorder.²⁴ If additional personal support is helpful, readers are encouraged to access the online resources and information about healthcare services related to psychosis and addiction listed below. 

Resources for personal support available in Toronto:

GTA Mental Health Resources – Culturally Specific | Health & Counselling Centre

Connex Ontario: Mental Health & Addiction Treatment Services

Partners in Care: Supporting Families in Patient Recovery

To Access CAMH Services, call 416 535-8501, option 2.

_________________________________________________________________________________

References

¹Saba, R. (2021, January 21). ‘We’ll have stores on pretty much every block’: Noticed a sudden surge in the number of pot shops in Toronto? Here’s why. Toronto Star. https://www.thestar.com/business/2021/01/19/more-cannabis-shops-keep-opening-despite-lots-of-competition-and-the-pandemic.html

²Hasin, D., & Walsh, C. (2020). Cannabis use, cannabis use disorder, and comorbid psychiatric illness: A narrative review. Journal of Clinical Medicine, 10(1), 1-19. doi10.3390/jcm10010015

³Loflin, M., & Earleywine, M. (2014). A new method of cannabis ingestion: The dangers of dabs?. Addictive behaviors, 39(10), 1430-1433. http://dx.doi.org/10.1016/j.addbeh.2014.05.013

⁴Government of Canada. (n.d.a). Addiction to cannabis. https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/health-effects/addiction.html

⁵Radhakrishnan, R., Wilkinson, S.T., & D’Souza, D.C. (2014). Gone to pot: A review of the association between cannabis and psychosis. Frontiers in Psychiatry, 5(54), 1-24. doi:10.3389/fpsyt.2014.00054

⁶Badcock, J., & Paulik, G. (2020). A clinical introduction to psychosis: Foundations for clinical psychologists and neuropsychologists. Elsevier.

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You’ve heard of mindfully meditating, but what about mindfully smoking?

By: Rhiannon Ueberholz

If you google “ways to improve your mental health” it’s likely that any results that pop up will contain some information on mindfulness. In our tech-dominated world, mindfulness has become a saving grace, as it allows us to shift away from our busy minds. Though often conflated with meditation, any activity can be done mindfully, including walking, eating, or making a pot of coffee – being mindful is simply:

• paying attention to what you are doing on purpose
• with an attitude of openness and curiosity (Kabat-Zinn, 2003). 

Mindfulness meditation is a specific type of meditation that involves sitting comfortably while paying attention to any thoughts or sensations in the body, accepting them, and allowing them to pass without judgment (Kabat-Zinn, 2003). You can even try it right now: stop what you’re doing, close your eyes or lower your gaze to the floor and take five deep breaths, in through the nose and out through the mouth. Your mind isn’t going to be completely blank, so just try to notice the thoughts that pop into your head without judgment, and then redirect your attention back to your breath. That’s mindfulness! Don’t worry if you found it difficult (most people do); luckily, it gets a lot easier with practice. 

While this may sound like a new-age wellness fad, as often associated with hippie-culture, the research has shown that practicing mindfulness can lead to improvements in stress, depression, insomnia, chronic pain, and anxiety (Grossman et al., 2014; Goldberg et al., 2018; Goyal et al., 2014). 

More recently, Psychologists have broadened mindfulness practice to treating nicotine addiction. Mindfulness treatments are different from other therapies because they target nicotine addiction by having patients accept their cravings (ie. the intense urge to smoke) and work through them, rather than avoiding or substituting nicotine with something else (Brewer et al., 2011). This can be compared to behavioural treatments, where a common technique would be to avoid places and items that trigger cravings, for example, someone avoiding the store where they buy their cigarettes (Larimer et al., 1999). In order to understand how mindfulness-based treatment works, it’s important that we have a clear understanding of nicotine addiction and why people continue to smoke when they know cigarettes are bad for them. 

Why do people get addicted to cigarettes in the first place?

The Incentive Salience Model describes addiction as a progression; people start smoking because it’s enjoyable until they eventually come to dislike it, but strong cravings make it difficult to quit (Robinson et al., 2016). 

A typical case might look like this: Bill smokes for the first time in a social setting; he enjoys the nicotine-induced head rush and looks cool for smoking in front of his peers. The next time Bill is at a party with his friends and sees a cigarette, the reward system in his brain will light up, reminding him of how much he enjoyed smoking last time he was at a party, and he will be motivated to smoke again (Robinson et al., 2016). This may also happen when Bill experiences negative events, for example stress from work or sadness from a breakup (Brewer et al., 2011). His brain will remember that smoking makes him feel good and will motivate him to smoke a cigarette to make himself feel better. Eventually, this turns into a habit and Bill develops stronger nicotine cravings whenever he experiences a stressful event, is out with friends or sees something that reminds him of smoking. Over time, Bill no longer experiences the same rewards from smoking; by now he’s developed a tolerance for nicotine, so he no longer experiences a head rush and his peers disapprove. Bill might try to quit by distracting himself or using sheer willpower, but whenever he gets tired or stressed, he may not have the mental resources to exert such willpower and end up smoking again (Brewer et al., 2011).

How does Mindfulness Treat Nicotine Addiction?

Mindfulness works to treat nicotine addiction in two ways (1) by allowing people to develop a natural disliking for smoking and (2) helping them cope with cravings (Brewer et al., 2011). In Dr. Brewer’s lab, he actually encourages people to smoke a cigarette while mindfully paying attention to how smoking makes them feel. His research shows that when people actually pay attention to the experience of smoking, for example noticing how the cigarette burns their throat, makes their breath taste bad, and gets smoke in their eyes, they are able to develop a natural dislike for it (Brewer et al., 2011). When people understand on a deeper level that they dislike smoking, they have a much easier time quitting as opposed to simply having the knowledge that smoking is bad for them.

Once people have this deeper sense of how smoking makes them feel, they can start to detach the feeling of craving from the actual behaviour of smoking a cigarette (Brewer & Kabat-Zinn, 2017). Someone adopting a mindfulness technique would be able to (1) notice when a craving occurs, (2) take inventory of the sensations in their body and their surrounding environment, and (3) reflect on their experience of mindfully smoking (ie. remember that they don’t actually enjoy it), rather than impulsively reaching for a cigarette (Klein & Brewer, 2021). They can now recognize the craving as simply a combination of different body sensations that are being triggered by their internal state or environment, which may help them to resist the urge to smoke. Repeatedly experiencing craving without smoking will eventually break the habit (Klein & Brewer, 2021). 

Since mindfulness is linked to improved emotion regulation, using mindfulness to quit may have secondary, positive effects for stress – which is often a trigger for smoking! (Penberthy et al., 2017) Bill, who is now trying to quit smoking using mindfulness, might notice that he always smokes a cigarette to calm down after getting in a fight with his spouse. If he replaces this habit with taking ten minutes to practice mindfulness, not only will he reduce the chances of reaching for a cigarette, but he may also be able to better cope with the stress of the fight (Guendelman et al., 2017).

Is Mindfulness Effective?

Mindfulness is a skill and can be quite challenging to develop; however, practicing it regularly has actually been shown to reduce the overall level of activity in an area of the brain linked to craving, the posterior cingulate cortex (Brewer et al., 2013). Mindfulness works by quieting down the “Default Mode Network”, which is a series of brain structures that are responsible for remembering the past and thinking about the future; the posterior cingulate cortex makes up part of this network (Garrison et al., 2015). One study by Dr. Westbrook and colleagues showed that when people with nicotine addictions practiced mindfulness while looking at photos of cigarettes, they rated their craving as lower and had less activity in this area of the brain, compared to participants who didn’t practice mindfulness while looking at the images (Westbrook et al., 2013). Observing the sensations of craving with mindful curiosity actually makes the brain less reactive to the smoking cues that might cause someone to smoke!

Recent studies have shown that mindfulness treatments can be more effective than other popular treatments in reducing the likelihood of relapse (Davis et al., 2014). In these studies, a mindfulness-based addiction treatment program is compared with a treatment program that uses common behavioural techniques for quitting smoking, like avoiding triggers. In one study Dr. Brewer, a top neuroscientist in the field of addiction, and his colleagues compared a four-week mindfulness program to the American Lung Association’s “Freedom from Smoking program”, cited as “America’s Gold Standard” for smoking cessation (American Lung Association, 2021). This program combines group support, behavioural techniques, and the option for nicotine replacement therapy (ie. nicotine patches) or smoking cessation medication (ie. Bupropion). They found that participants in the mindfulness group had greater success in quitting without relapse seventeen weeks after both programs ended (Brewer et al., 2011). One participant in a mindfulness treatment program reported that they had smoked twenty cigarettes a day for 35 years, but after using a mindfulness-based app for smoking cessation, they were able to quit after just 6 days (Craving to Quit, 2021).

The most important takeaway from this research is that mindfulness is a new tool that can be incorporated into personalized treatment for addiction, not that it’s the best and only treatment. Mindfulness treatments may be effective on their own or often, treatment programs will combine mindfulness with other techniques depending on the needs of the individual. For example, the combination of mindfulness training and taking smoking cessation medication has shown to be more effective than taking medication alone. In a study by Dr. Gifford and colleagues, 32% of the participants who did a combination of therapy that incorporated mindfulness, and bupropion were successful in quitting smoking at a one-year follow-up, compared to 18% who just took medication (Gifford, 2011). An example of one program that uses multiple approaches is “Mindfulness Training for Smokers”, offering medication, mindfulness training, cognitive behavioural therapy, and skills training to combat nicotine addiction (Davis, 2021).

What are the Limitations?

It’s important to note, that while mindfulness has shown promise, it can be quite difficult and may not work for everyone depending on their circumstances. Developing a mindfulness practice takes time and effort, and therefore it would be important for the individual to be highly motivated. Additionally, since using mindfulness-based treatment requires that the person comes to an understanding that they don’t actually enjoy smoking, people who don’t consider their addiction to be that severe and subjectively enjoy cigarettes may not be as invested in a mindfulness approach. This was found in Davis’s and colleagues’ study; people who smoked fewer cigarettes per day were more likely to drop out of the mindfulness program compared to people who smoked more frequently (Davis et al., 2014). 

Mindfulness programs for smoking have just recently become more common and are still being tested (Spears et al., 2019). While there have been studies that found mindfulness treatments to be more effective than standard treatments, there have also been studies that found no difference when comparing treatment approaches (Goldberg et al., 2018). This is quite common when developing new treatments, but doing more research will help to find the most effective ways to implement mindfulness for nicotine addiction. 

Getting Help During the Pandemic

Amidst the COVID-19 pandemic, studies have found that people who had low levels of nicotine addiction before the pandemic are more likely to experience moderate or high levels of addiction, potentially due to increased stress (Fidanci et al., 2021). Interestingly, it has been found that during the pandemic more people are quitting smoking, rather than starting, which may be the result of anxiety surrounding the increased risk of COVID-19 complications for smokers (Yang & Ma, 2021).

 If you or someone you know is having a hard time quitting, mindfulness might be the perfect tool! There are some mindfulness-based apps that can offer support while face-to-face treatment programs are unavailable.  One mindfulness program for nicotine addiction is Dr. Brewer’s mindfulness-based app, Craving to Quit. This virtual program teaches mindfulness-based exercises to manage cravings, provides personal coaching, and connects users to an online peer community. The program is designed to be 21 days; however, it’s designed to offer support for as long as the client needs. 

All things considered, we are living in very stressful times. Developing a mindfulness practice can be a useful tool to reduce stress, depression, and anxiety, whether you’re struggling with a nicotine addiction or not. Try to focus on the things you can manage in the present moment and everything else will fall into place. 

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