COVER PAGE

DEMOGRAPHIC DATA

Name: JKM

Patient number: 231833

Age: 28 years

Gender: Male

Tribe: mchaga

Religion: Christian

Marital Status: Single

Occupation: Boda-boda rider in Dar es Salaam

Education: Form 4 dropout

Residence: Lives in a shared single room in Kariakoo

Informant: self-informant

Next of kin: his mother

Referral Source: self-referral to Mwananyamala Regional Referral Hospital

DOC: 27/06/2025

MAIN COMPLAINT

Seeking help with his cannabis addiction after unsuccessful attempts to quit for
the past two years."
HISTORY OF PRESENTING ILLNESS
He first tried bangi at age 22 with friends in nightclubs. It started with just two
cigarettes a day, but over time, he increased to ten per day. He used to smoke
before and during work. He reported experiencing calmness, sleepiness, and
increased appetite when using cannabis. But on days he didn’t take it, he
couldn’t sleep, lost his appetite, and felt restless At times, after heavy cannabis
use, he would feel overly aggressive ,suspicious or anxious, as if people were
watching him However, he never experienced auditory or visual hallucinations.
He denies any history of suicidal or self-harm ideation but acknowledges
needing help to break free from this cycle.
Two years ago, he admitted himself to the hospital after receiving treatment,
he remained drug-free for several months before relapsing again. He has
relapsed three or four times since then, these cravings come and go
throughout the day, especially when he is stressed or in social situations. Even
though he knows cannabis is ruining his life, he can’t stop thinking about
obtaining and using it. His addiction has caused significant problems. He has
become more aggressive, leading to frequent conflicts with family and friends.
Additionally, he smokes 1 to 2packs of cigarettes a day, tobacco and consumes
alcohol regularly.
HIS MOTHER reported that, He changed completely. He used to be active and
responsible, but then he started isolating himself, neglecting his duties, and
losing interest in everything except cannabis. His mood swings and aggression
made it difficult to live with him. We’ve tried to help him quit many times, but
he always returned to using.

Past Psychiatric History

The patient takes cannabis (bangi), tobacco, and alcohol. His cannabis use
began at age 22 with an initial intake of two cigarettes daily, progressively
escalating to ten cigarettes per day. No formal psychotic or mood disturbances
—such as hallucinations and delusions were reported. Though he reported
intermittent anxiety and anger or aggressiveness, he had no history of mood
disorders.
Medical History:
The patient denies any chronic medical conditions but reports frequent
morning cough likely related to his heavy cannabis and tobacco use. He has
long history of Git upset and Gastric PAIN. He has no known drug allergies and
has never undergone major surgical procedures. His last HIV test was six
months ago which was negative, he has no history of blood transfusions. The
patient reports occasional use of over-the-counter pain relievers for headaches
but denies using any other prescription or recreational drugs beyond cannabis,
tobacco, and alcohol.

Family History:
She reported no family history of psychiatric illness, though she mentioned the
patient's father and paternal uncle had patterns of heavy alcohol use and
cigarette smoking. The parents divorced when the patient was 10 years old,
after which he was raised primarily by his mother. The mother denied any
family history of suicide attempts or hospitalizations for mental health
conditions, though she noted some relatives had struggled with substance use
behaviours similar to the patient's current pattern.

Personal and Social History:

The patient was born and raised in Dar es Salaam, achieving normal
developmental milestones. His mother described him as having been an active,
sociable child who enjoyed football and school. Financial constraints led him to
drop out after completing Form 4 education, after which he began working as a
boda-boda rider. While his parents' early divorce created some childhood
instability, his mother emphasized he had adjusted well until his cannabis use
began two years ago. Over the past two years, his mother observed
progressive social withdrawal, declining work performance, and loss of interest
in previous activities. His romantic relationship has become strained due to
behavioural changes associated with his substance use.
Review of Other Systems:
Cardiovascular: He denies chest pain, palpitations, or syncopal episodes. No
history of hypertension, peripheral enema, or claudication reported.
Respiratory: Reports chronic morning cough productive of white sputum and
occasional wheezing, particularly after heavy smoking. Denies haemoptysis,
dyspnoea at rest, or recurrent respiratory infections.
Gastrointestinal: Reports long-standing gastric pain and recurrent
gastrointestinal upset, including epigastric discomfort and bloating. Denies
nausea, vomiting, hematemesis, or melena. Appetite fluctuations correlate
with cannabis use patterns.
Genitourinary: Denies dysuria, haematuria, or urinary frequency. No sexual
dysfunction reported unrelated to substance use.
Neurological: No seizures, tremors (beyond mild withdrawal-related
shakiness), or syncope. Denies headaches (except occasional tension, focal
weakness, or sensory changes.
Musculoskeletal: No joint pain, swelling, or mobility limitations reported.

Mental Status Examination (MSE)

The patient presents as a thin, RED conjunctivae and a mild hand tremor.
Speech is mildly slowed but remains coherent and logical. He describes his
mood as "restless" with congruent anxious affect. Thought Process: Goal-
directed; no evidence of psychosis. Thought Content: Preoccupied with
cravings but no delusions. Perception: No hallucinations or illusions. He
demonstrates no current delusions or perceptual disturbances. Cognitive
screening reveals mild attentional deficits but intact orientation and memory.
Insight is partial - he acknowledges problematic use but minimizes its severity.
Judgment appears impaired regarding consequences of continued substance
use.
Physical Examination:
General physical examination reveals a thin-built male with normal vital signs.
Notable findings include nicotine stains on his fingers, mild gingivitis, and
scattered wheezes on lung auscultation. Abdominal examination is
unremarkable with no hepatomegaly. Neurological examination is normal
apart from the previously noted mild postural tremor.
Summary of Findings:
This 28-year-old boda-boda rider presents with a 2 year history of progressive
cannabis use disorder characterized by tolerance, withdrawal symptoms, and
multiple failed quit attempts despite previous treatment. His case is
complicated by concurrent heavy tobacco use and alcohol consumption,
significant occupational impairment and relationship strain, and high-risk
environmental factors maintaining his substance use. The absence of psychotic
features or other primary psychiatric symptoms helps distinguish this as a
substance-induced disorder rather than a psychotic illness.

Diagnosis & Differentials

 Provisional Diagnosis: Cannabis Use Disorder
Defence: Meets ≥4 DSM-5 criteria (tolerance, withdrawal, neglect of roles).
Differentials:
 Generalized Anxiety Disorder (ruled out: anxiety secondary to use).
 Depressive Disorder (ruled out: anhedonia only during withdrawal)

5PS FRAMEWORK OF BIOPSYCHOSOCIAL MODEL OF HEALTH

FACTORS BIOLOGICAL PSYCHOLOGICAL SOCIAL
1. Presenting Severe cannabis
Problem use disorder with
tobacco and - -
alcohol
dependence
2. Predisposing Early substance Limited Socioeconomic
Factors exposure education stress
3. Precipitating Poor coping skills Peer pressure,
Factors work
environment
4. Perpetuating Continued access Cannabis-using
Factors to substances social network
5. Protective Preserved insight, Family support
Factors previous
treatment
engagement
INVESTIGATIONS
1. Biological Investigations. Laboratory Tests
 Complete Blood Count (CBC)
Reason: Rule out anaemia (common with poor nutrition) or infections (e.g.,
HIV in high-risk groups).
 Liver Function Tests (LFTs)
Reason: Cannabis use (especially with alcohol/tobacco) may cause mild liver
enzyme elevations.
 Renal Function Tests (RFTs)
Reason: Baseline for medication clearance (e.g., gabapentin, NAC).
 Thyroid Function Tests (TFTs)
Reason: Hypothyroidism can mimic withdrawal symptoms (fatigue,
depression).
 Urine Toxicology Screen
Reason: Confirm cannabis use, detect drug use (e.g., opioids, stimulants).
 Vitamin/Mineral Levels B12, Folate, Iron, Magnesium
Reason: Deficiencies linked to fatigue, cognitive impairment, and mood swings.
 Chest X-ray
Reason: Chronic cannabis smokers may develop lung inflammation or bullae.

2. Psychological Investigations Standardized Assessments

 Cannabis Use Disorder Identification Test (CUDIT)
Reason: Quantifies severity of CUD (e.g., cravings, social impact).
 Patient Health Questionnaire (PHQ-9) / Generalized Anxiety Disorder-7
(GAD-7)
Reason: Screen for depression/anxiety (common in CUD).
 Mini-Mental State Examination (MMSE)
Reason: Assess cognitive deficits (e.g., memory, attention) from chronic use.
3. Social Investigations Structured Tools
 Addiction Severity Index (ASI)
Reason: Evaluates impact on employment, legal status, and family dynamics.
 Social Support Survey
Reason: Determines availability of family/friends for recovery support.
 Qualitative Assessments Home/Work Environment Review
Reason: Identify exposure to cannabis (e.g., peers who use, workplace stress).

MANAGEMENT

Management

Biological Psychological Social

Haloperidol 5mg PO
Propranolol 20mg BID (for
tremors/anxiety) or Gabapentin Refer to
Motivational
Immediate 300mg TDS (for cravings + social
interviewing
withdrawal). worker
Quetiapine 25–50mg (if sleep
disturbances persist).

Antianxiety(diazepam) CBT for Support

Short-
relapse groups
term Anti-depressant (fluoxetine) prevention (NA)

Monitor for relapse

Vitamin B1 (Thiamine) 100mg
daily (for alcohol-related
deficiency). Family Vocational
Long-term
Omega-3 1g daily (evidence for therapy rehab
mood stabilization).
Prognosis:
This patient has a poor to fair prognosis because:

 Bad Signs:

He's addicted to multiple substances (cannabis, tobacco, alcohol)

Has failed to quit 3-4 times already

Doesn't have good ways to handle stress without drugs

 Good Signs:

He once stayed clean for 6 months (shows he can do it)

Came for help on his own (wants to change)

Has family support (his mother helps him)

Understands some of his drug problems