Case 1

A 32-year-old female with a psychiatric history of post-traumatic stress disorder (PTSD), borderline personality disorder, self-harming behaviors, drug overdose, and depression presented to the emergency department with heightened paranoia, delusions, and auditory hallucinations. She reported hearing her neighbors’ voices through the speakers on her floors and expressed concerns that they were tampering with her belongings and intending to harm her. Her extreme paranoia and discouraging voices prevented her from seeking help. She complained of constant suicidal ideation and admitted to contemplating jumping from a bridge.

In the emergency room, she received olanzapine 10 mg and lorazepam 3 mg to manage her symptoms. On admission, her vital signs included a blood pressure of 189/106 mmHg, a heart rate of 114 bpm, a respiratory rate of 30 breaths per minute, and a temperature of 97.5°F. Laboratory workup, including a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, and free T4 levels, was unremarkable. A urine drug screen was positive for cannabinoids. Her home medications included propranolol 10 mg twice daily, sumatriptan 50 mg as needed for headaches, lorazepam 0.5 mg as needed for panic attacks, and buspirone 15 mg twice daily. She was diagnosed with psychosis unspecified and PTSD.

On admission, she displayed disorganized behavior, increased psychomotor activity, anxiety, and restlessness. She appeared anxious and paranoid, frequently scanning her environment, with a labile and tearful affect. Her thought content included paranoid and delusional ideation but no homicidal or suicidal plans. During hospitalization, she was started on risperidone for psychotic symptoms, clonidine for blood pressure management, and trazodone for sleep and PTSD-related nightmares. The risperidone dose was titrated up to 1.5 mg twice daily, and she responded well to treatment.

During her hospitalization, she reported that her mental health had deteriorated over the past year, coinciding with the escalating use of Δ8-THC gummies while working at a store selling Δ8-THC products derived from hemp-based CBD. As her consumption increased, she experienced worsening paranoia, disrupted sleep, and auditory hallucinations. She eventually quit her job. Despite prior use of illicit substances, including marijuana since the age of 17, she had not previously experienced psychotic episodes.

After 13 days in the hospital, she returned to her baseline functioning. She was discharged on risperidone 1.5 mg twice daily, clonidine 0.2 mg three times daily, trazodone 300 mg at bedtime, and hydroxyzine 25 mg as needed for anxiety up to three times daily. She was advised to abstain from all cannabis products, including marijuana and Δ8-THC. At her outpatient psychiatric follow-up, her psychotic symptoms had resolved, and she continued to respond well to treatment.

Case 2

A 27-year-old male with a psychiatric history of substance (cannabis)-induced psychosis, hallucinations, self-harming behaviors, and depression, as well as a prior psychiatric admission a year ago, presented to the emergency department with disorganized behavior and confusion. He was accompanied by his cousin, who was concerned after his unannounced visit from another city and multiple encounters with the police due to car-related issues. He had recently been fired from his job for repeated absences.

His cousin suspected he had relapsed into cannabis use, as his bizarre behavior resembled the psychotic episode that led to his hospitalization the previous year. The patient described experiencing “neurosis” and increased stress at work. He reported poor sleep and stated that he did not remember how he had made it to her house. While he denied hallucinations, he exhibited confusion and a detached demeanor during the assessment. An admitting diagnosis of psychosis unspecified was made, with a differential diagnosis of substance-induced psychosis.

His prior hospitalization had been due to cannabis-induced psychosis, for which he was treated with olanzapine and advised to discontinue cannabis use. He had successfully stopped using cannabis and had been making progress in his life. However, in recent months, he began using legally procured Δ8-THC gummies from a CBD store to manage anxiety and depression, believing them to be a safe and legal alternative to marijuana.

On admission, his vital signs included a blood pressure of 140/90 mmHg, a heart rate of 106 bpm, a respiratory rate of 16 breaths per minute, and a temperature of 36.5°C (97.7°F). A urine drug screen was positive for cannabinoids. He admitted to consuming a delta-8 edible the night before admission. He was dressed appropriately but exhibited slowed psychomotor activity, poor eye contact, and a flat affect. His thought process was disorganized, with difficulty focusing and concentrating. He appeared lost in thought and showed signs of responding to internal stimuli.

He was admitted to the psychiatric unit for stabilization. Initially, he remained isolated in his room with a flat affect. He was started on fluphenazine 2 mg three times daily, in addition to his home dose of bupropion for depression. Trazodone and propranolol were prescribed for sleep and anxiety. After 11 days in the inpatient psychiatric unit, he returned to his baseline functioning. He was discharged on fluphenazine decanoate 12.5 mg intramuscular injection every 14 days, along with oral fluphenazine 1 mg twice daily. He returned to his hometown but was subsequently lost to follow-up.

Case 3

A 21-year-old male with no prior psychiatric history or hospitalizations was brought to the emergency department by his aunt due to bizarre behavior and grandiose delusions. His family reported that he believed he could fly and was found on a bridge, expressing a desire to jump off to safety. He had been reported missing a few days earlier and was later found swimming in a river. He claimed to have been assaulted and presented with multiple abrasions. Upon evaluation, he exhibited rapid speech, flight of ideas, and a tendency to relate his experiences to Buddhism.

In the emergency room, he received olanzapine and lorazepam. A urine drug screen was positive for cannabinoids. On admission, his vital signs included a blood pressure of 142/58 mmHg, a heart rate of 122 bpm, a respiratory rate of 20 breaths per minute, and a temperature of 36.1°C (97°F). Psychiatric assessment revealed increased psychomotor activity, restlessness, an irritable and labile affect, pressured speech, and a disorganized thought process. He endorsed grandiose delusions and demonstrated poor insight and judgment, consistent with acute mania. An initial diagnosis of psychosis unspecified was made, with a differential diagnosis of bipolar mania with psychosis and substance-induced psychosis.

During his hospitalization, he remained hyperactive, continued expressing grandiose delusions, and discussed involvement with gangs. He also expressed interest in obtaining a prescription for medical marijuana to manage his anxiety. He required frequent redirection for intrusive behaviors. He admitted to regularly smoking Δ8-THC (AK47), which he had purchased from an online store.

He was started on quetiapine and divalproex sodium, which were titrated to 600 mg and 1,500 mg daily, respectively. His manic symptoms gradually subsided, and he was discharged after 17 days. Outpatient treatment was initiated; however, two weeks later, he relapsed, began using alcohol, discontinued his medications, and presented to the emergency department with a recurrence of symptoms. He was readmitted, and his medications were adjusted. Due to elevated ammonia levels associated with divalproex and quetiapine, his treatment regimen was switched to lithium and olanzapine.

Following his second discharge, he has maintained adherence to treatment, abstained from cannabinoids and alcohol, and has not required further hospitalization.

The laboratory results on admission for all three cases are presented in Table 1.