A new case report documents paranoid psychosis developing in a 67-year-old woman approximately four weeks after she abruptly stopped heavy, long-term cannabis concentrate use. Her symptoms resolved fully with short-term antipsychotic treatment. While this adds to a small but growing literature on cannabis withdrawal-associated psychosis, a single case cannot establish causation, and clinicians should interpret it as hypothesis-generating rather than definitive.

Cannabis use among older adults is rising faster than in any other demographic, yet this population remains profoundly understudied when it comes to psychiatric complications of both use and cessation. Most clinical attention to cannabis-related psychosis has focused on intoxication states in younger people, leaving a significant awareness gap around withdrawal-associated presentations. As high-potency concentrates become more widely available and older patients with complex psychiatric histories increasingly use cannabis for symptom management, clinicians need to understand that the cessation period itself may carry its own psychiatric risks.

Cannabis withdrawal syndrome is recognized in the DSM-5 and typically includes irritability, anxiety, insomnia, and appetite changes, but psychosis is not currently listed among its diagnostic features. However, a small but growing body of case literature has described psychotic episodes emerging during cannabis withdrawal rather than intoxication. This case report describes a 67-year-old woman with established major depressive disorder, generalized anxiety disorder, and PTSD who had been using approximately 3 grams per day of high-THC cannabis concentrates (wax) for six years. She abruptly discontinued all cannabis use, and roughly four weeks later, she developed paranoid delusions centered on surveillance themes and thought broadcasting, along with suicidal ideation. Her medical workup, including comprehensive metabolic panel, thyroid studies, inflammatory markers, vitamin levels, and brain MRI, was unremarkable aside from chronic microvascular white matter changes.

The patient required two psychiatric hospitalizations. After her first discharge on risperidone 0.5 mg nightly, she discontinued the medication, and her symptoms returned severely within two days, necessitating readmission to a geriatric psychiatry unit. With sustained antipsychotic treatment alongside escitalopram, buspirone, and hydroxyzine, her psychotic symptoms resolved fully over approximately four months, and risperidone was subsequently discontinued without recurrence. The authors frame this presentation as consistent with cannabis withdrawal-associated psychosis, noting that her risk profile aligns with features identified in Chesney and colleagues’ 2024 systematic review: heavy daily use, prolonged duration, high-THC products, and pre-existing psychiatric vulnerability. They are careful to acknowledge that a single case cannot establish causation and that the coincidental emergence of a primary psychotic disorder cannot be excluded.

This case is clinically interesting precisely because the psychosis appeared after cessation, not during active use. That temporal pattern challenges the more familiar narrative where cannabis-related psychosis is understood as an intoxication phenomenon. The report is well-documented and the authors are admirably restrained in their claims. Still, we have to be honest about what one case can and cannot tell us. This patient had multiple pre-existing psychiatric conditions, was on several medications, and was 67 years old with microvascular brain changes. Any of these factors could have contributed, and separating “cannabis withdrawal” from the broader clinical context is not something a case report can do.

In my own practice, I always discuss tapering rather than abrupt cessation when a patient on heavy cannabis decides to stop, and I emphasize this more strongly for older patients or those with psychiatric comorbidities. This case reinforces that approach. I also make a point of following up actively during the weeks after cessation, not just at the time of the decision. The period after quitting deserves as much clinical attention as the period of active use, and this report is a reminder that the post-cessation window is not necessarily benign.

For clinicians, this case sits within a very early research arc. Cannabis withdrawal-associated psychosis is not a validated diagnostic entity; it is a proposed clinical pattern supported by scattered case reports and one systematic review of modest scope. The evidence base is far too thin to support screening protocols, formal risk stratification tools, or treatment algorithms. However, the aggregate pattern across published cases is at least consistent enough to justify heightened clinical awareness. Older adults who discontinue heavy, long-term cannabis use, particularly high-THC products, and who carry pre-existing psychiatric diagnoses, may warrant closer monitoring in the weeks following cessation.

From a pharmacological standpoint, the use of low-dose risperidone in this patient proved effective, and the transient nature of the psychosis, resolving within months and not recurring after antipsychotic discontinuation, is noteworthy and somewhat reassuring. Clinicians should be aware that abrupt cessation of heavy cannabis may produce a broader and more severe withdrawal syndrome than DSM-5 currently captures. The single most practical recommendation from this case is straightforward: when managing cannabis cessation in psychiatrically vulnerable older adults, consider a gradual taper, schedule follow-up visits within the first four to six weeks post-cessation, and maintain a low threshold for psychiatric assessment if new or unusual symptoms emerge during that window.

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