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Received 28 May 2002; received in revised form 22 January 2003; accepted 19 February 2003
Abstract
The study’s objective was to investigate in a non-clinical population the association between cannabis use and
anxiety in daily life using the Experience Sampling Method (ESM). Seventy-nine subjects with high or low levels
of cannabis use were selected among a sample of 685 undergraduate university students. ESM was used to collect
information on cannabis use and state-anxiety in daily life. DSM-IV diagnoses were assessed using a structured
clinical interview. Statistical analyses were performed using multilevel linear random regression models. There was
no significant association between the level of state anxiety and cannabis use in daily life. However, a diagnosis of
agoraphobia was significantly associated with increased likelihood of cannabis use, independent of state anxiety and
other confounding factors. No evidence was found for an anxiolytic or anxiogenic effect of cannabis in daily life.
This finding does not support the hypothesis that subjects with high levels of anxiety use cannabis as a means of
self-medication. The association between agoraphobia and cannabis use in daily life may be explained by anticipatory
anxiety secondary to previous cannabis-induced panic-like symptoms.
Q 2003 Elsevier Science Ireland Ltd. All rights reserved.
0165-1781/03/$ - see front matter Q 2003 Elsevier Science Ireland Ltd. All rights reserved.
doi:10.1016/S0165-1781(03)00052-0
2 M. Tournier et al. / Psychiatry Research 118 (2003) 1–8
cannabis (Hollister, 1986; Thomas, 1996). Other the application of data collection techniques more
studies have suggested that cannabis use may be capable of capturing the brief life cycle of this
associated with long-lasting anxious symptomatol- association, such as the Experience Sampling
ogy. In a study of persons who regularly used Method (ESM) (Csikszentmihalyi and Larson,
cannabis for at least 10 years, Reilly et al. (1998) 1987; Swendsen and Norman, 1998; Swendsen et
found that 21% of these subjects had high levels al., 2000).
of state anxiety, and several case reports have The objectives of the present study using ESM
described cannabis-induced agoraphobia (Moran, in a population of students were as follows: (1) to
1986) and panic disorder (Deas et al., 2000; Langs assess rapid changes in state anxiety levels in
et al., 1997). response to cannabis use in daily life; (2) to
Few epidemiological investigations have exam- determine whether subjects with a diagnosis of
ined the comorbidity of anxiety disorders and anxiety disorder were more likely to use cannabis
cannabis use in the general population. Using data over the ESM follow-up period.
from the Australian National Survey of Mental
Health and Well-Being, Degenhardt et al. (2001) 2. Method
have reported an association between cannabis use
over the past year and increased prevalence of 2.1. Subjects
anxiety disorders. Among individuals with canna-
bis dependence, 17% had at least one anxiety 2.1.1. Baseline screening
disorder compared to 5% of non-users. However, The method has been described in detail in
this association disappeared after adjustment for previous work (Verdoux et al., 2002). Undergrad-
demographic characteristics, personality disorder uate university students were invited to participate
and use of others drugs. Although these studies in a study of daily life behavior and experiences.
suggest that an association may exist between After receiving a full description of the study,
cannabis use and high levels of trait or state subjects provided written informed consent to par-
anxiety, they are not informative concerning the ticipate. A standardized self-report questionnaire
direction of this association (Compton et al., 2000; was used to collect information on demographic
McGee et al., 2000; Mueser et al., 1998). That is, characteristics and substance use. Subjects were
it is currently unclear if anxiety is best conceptu- asked to specify the frequency of use over the last
alized as a consequence of cannabis use in vulner- month (ranging from 1: never in the past 30 days
able subjects, or conversely, if anxiety disorders to 7: several times a day) concerning diverse
may favor cannabis use. An additional possibility psychoactive substances including cannabis and
is that both cannabis use and anxiety disorders alcohol. Psychosis proneness was assessed using
may be independently induced by a shared risk the Community Assessment of Psychic Experienc-
factor, such as specific pre-existing personality es (CAPE) (Stefanis et al., 2002; Verdoux et al.,
traits. 2002).
The inability of the existing literature to differ-
entiate between the diverse potential explanations 2.1.2. Selection of the ESM group
for the association of cannabis and anxiety is due The baseline sample included all students
in part to the fact that their relation is likely to be attending an information meeting on course organ-
restrained to a brief time period (such as a few ization at the beginning of the university year. Of
hours). As such, standard assessment techniques the 685 subjects invited to participate in the survey,
(used to compute ‘average’ anxiety levels, diag- 649 fully completed the self-report screening ques-
nostic status, or cannabis use over longer time tionnaire. The sample included 586 females and
intervals) are unable to sufficiently investigate the 63 males, consistent with the skewed gender dis-
rapid interaction of these variables. Studies exam- tribution of students in psychology. The 649 sub-
ining fluctuations of anxiety levels and their rela- jects had a mean age of 20 (S.D. 3) years; most
tion to cannabis use should therefore benefit from of them (ns619, 95.7%) were single. Nearly one
M. Tournier et al. / Psychiatry Research 118 (2003) 1–8 3
out of three subjects (ns194, 29.9%) had used Responding to randomly programmed signals from
cannabis over the last month (once in the past portable electronic devices, subjects are asked to
month, ns46; two or three timesymonth, ns46; describe their present experience by answering a
once a week, ns26; 2-3 timesyweek, ns33; once brief questionnaire several times a day over con-
a day, ns22; more than once a day, ns21). The secutive days. During an ESM training session,
median (interquartile range, IQR) CAPE positive subjects were instructed on how to complete each
score was 29 (26–33). item of the ESM form and to complete the form
In order to maximize the probability of observ- at each signal of a multi-alarm wristwatch. Sub-
ing sufficient variance in cannabis use in daily jects were then studied in their daily living envi-
life, a stratification procedure involving cannabis ronment. Over 7 consecutive days, the watch
(tetrahydrocannabinol; THC) consumption was emitted five alarm signals per day at randomized
used to create a sample for the ESM phase. THC moments within each of the following time per-
consumption over the last month was categorized iods: 08.00–11:00 h; 11.00–14.00 h; 14.00–17.00
into ‘low THC’ (no use over the past month, ns h; 17.00–20.00 h; and 20.00–23.00 h.
455, 70.1%) vs. ‘high THC’ (more than once a The ESM form collected information concerning
week, ns76, 11.7%). Respondents were also substance use for the period between the current
selected on the basis of responses to the self-report and previous signals (corresponding on average to
questionnaire of psychosis-proneness (PP), a var- the previous 3 h), as well as state anxiety at the
iable not examined by the present study but con- moment of the signal. Substance use was explored
trolled for in all analyses (see Verdoux et al., by the question: ‘Over the last period, did you use
2003). Within each THC group equal numbers of any substances?’ (YesyNo), followed by an open
subjects with ‘low PP’ (0–27), ‘medium PP’ (28– question, ‘if, yes, which substance(s) did you use?’
33), or ‘high PP’ (34–76) were randomly selected. The level of state anxiety was assessed on the
Since the baseline sample included less than 10% experience sampling form using a seven-point
males, a higher proportion of male subjects were Likert scale that asked participants to evaluate
sampled within each THCyPP group in order to their level of anxiety at that moment, ranging from
increase the sex ratio (30% of males). Research 1 (not at all anxious) to 7 (extremely anxious).
psychologists blind to the selection criteria for
each individual telephoned subjects selected 2.3. Clinical interviews
according to this stratification method, and those
agreeing to participate in the other phases of the
At the end of the ESM phase, the subjects were
study received financial compensation (775).
interviewed using the Mini International Neuropsy-
Of the 88 subjects invited to participate in the
chiatric Interview (MINI, 4.4 version) by two
ESM phase of the study, seven declined to partic-
research psychiatrists blind to the risk status of
ipate and two were excluded at the completion of
subjects (cannabis use history) as well as with
the study due to deviations from the established
regard to their ESM data. The MINI is a short
procedures. There were no significant differences
diagnostic interview designed to be used in non-
with regard to demographic and clinical variables
clinical populations (Lecrubier et al., 1997). This
between these subjects and those included in the
instrument was designed to assess current and
ESM phase.
lifetime diagnoses of psychiatric disorders accord-
2.2. ESM procedure ing to DSM-IV criteria (American Psychiatric
Association, 1994), including diagnoses of anxiety
ESM is an ambulatory self-assessment method disorders and substance use.
designed to collect information on subjective expe-
rience occurring over time in naturalistic settings 2.4. Statistical method
(Csikszentmihalyi and Larson, 1987; Swendsen
and Norman, 1998; Swendsen et al., 2000). Statistical analyses were conducted using
4 M. Tournier et al. / Psychiatry Research 118 (2003) 1–8
any, should have attenuated the strength of the daily life is in apparent contrast to its association
association between cannabis and anxiety if sub- with anxiety disorders. This latter association was
jects who underreported cannabis use were also independent of the level of state anxiety, and thus
more likely to underestimate their level of state cannot be explained by the fact that subjects with
anxiety. anxiety disorders preferentially used cannabis
As we used a unimethod approach to measure when they were anxious. One explanation for this
anxiety, we cannot exclude that different findings finding is supported by investigations demonstrat-
would have been obtained if we had used measures ing that panic-like symptoms are the most frequent
of changes across multiple systems (biological, adverse effects of cannabis use, particularly among
cognitive, and behavioral). inexperienced users (Tunving, 1987; Thomas,
1993; Hall and Solowij, 1998). Cannabis-induced
4.2. Interpretation of findings
panic attacks may provoke an anticipation anxiety
and promote panic disorder among subjects with a
The first hypothesis tested in the present study
high level of anxiety sensitivity (Barlow, 1988;
was to assess changes in state anxiety in response
to cannabis use in daily life. The fact that no Langs et al., 1997; Deas et al., 2000). In addition,
significant cross-sectional or sequential associa- the lack of a significant association between panic
tions were found between cannabis use and the disorder and cannabis use in the present study may
level of state anxiety could be interpreted as a therefore be explained by a deterrent effect of full
general lack of association between cannabis and panic attacks, as has been observed for caffeine
anxious symptomatology. While individuals may (Boulenger et al., 1984). A speculative hypothesis
indeed mention relaxation, stress and anxiety regarding the association of cannabis use and
reduction as their motivation for using cannabis agoraphobia concerns the emergence of anticipa-
(Boys et al., 1999), our findings do not support tory anxiety secondary to previous cannabis-
the hypothesis that most subjects with high levels induced panic-like symptoms. Moran (1986)
of anxiety use cannabis to self-medicate anxious reported six cases of subjects with a cannabis-
symptoms (Stewart et al., 1997). Indeed, there are induced experience of depersonalization who
many tenable explanations for cannabis use which developed anticipatory anxiety, then agoraphobia.
include conviviality, recreational purposes, social Subjects presenting with acute depersonalization
enhancement or affiliation to a peer group (Webb may not associate the subsequent occurrence of
et al., 1996; Stewart et al., 1997; Swift et al., agoraphobic symptoms to cannabis use, and may
2000), any of which could have masked its pos- thus continue to use this drug despite the devel-
sible association with anxiety. However, a signifi- opment of agoraphobia. However, the interpreta-
cant association was nonetheless found in this tion of these findings is limited by the fact that
sample concerning state anxiety and alcohol use the temporal relationship between cannabis use
(a substance also consumed for heterogeneous and agoraphobia has not been explored in this
reasons; Swendsen et al., 2000). We therefore have
study. Future investigations of this association may
no reason to suspect that the diversity of motiva-
benefit from integrating experience sampling meth-
tions for cannabis use should prevent detection of
odology into prospective investigations with fol-
a specific association with anxiety, should it exist.
The second hypothesis tested in the present low-ups over longer durations.
study was to assess whether subjects with a diag-
nosis of anxiety disorder were more likely to use Acknowledgments
cannabis over the ESM follow-up period. We
found a diagnosis of anxiety disorders was asso-
ciated with an increased likelihood to use cannabis We thank Olivier Grondin, Mathilde Husky, and
over the naturalistic assessment. The lack of anx- Nadia Chakroun for their help in the organization
iolytic or anxiogenic effects of cannabis use in of the survey and in data entry.
8 M. Tournier et al. / Psychiatry Research 118 (2003) 1–8