Differential Diagnosis

• Single most likely diagnosis
  • Cannabis Withdrawal Syndrome: The patient's recent cessation of marijuana use after 11 years is a strong indicator for this diagnosis, given the symptoms of severe anxiety, sleep disturbances, and the timeline of these symptoms following marijuana cessation.
• Other Likely diagnoses
  • Anxiety Disorder: The patient's symptoms of severe anxiety could also suggest an underlying anxiety disorder, potentially exacerbated by the cessation of marijuana use and compounded by his concerns about employment.
  • Substance-Induced Anxiety Disorder: Given the patient's long-term use of Adderall and recent cessation of marijuana, it's possible that his anxiety is substance-induced, either from the effects of Adderall or the withdrawal from marijuana.
  • Depression with Anxious Distress: The patient's reported depression about not being employed, coupled with severe anxiety, could indicate a depressive disorder with significant anxious distress, though the primary complaint seems to be anxiety and sleep disturbance.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Thyroid Storm (despite normal TSH): Although the TSH is normal, thyroid function can sometimes fluctuate, and severe anxiety and sleep disturbances could be indicative of a thyroid storm, especially if the patient has a history of thyroid disease.
  • Pheochromocytoma: This rare tumor of the adrenal gland can cause episodes of severe anxiety, sleep disturbances, and other symptoms due to excessive catecholamine release. It's crucial to consider, despite its rarity, due to its potential lethality if missed.
  • Acute Coronary Syndrome or Cardiac Issues: Severe anxiety and sleep disturbances can sometimes be atypical presentations of cardiac issues, including acute coronary syndrome, especially in younger patients with risk factors (e.g., long-term stimulant use).
• Rare diagnoses
  • Bipolar Disorder: The patient's use of Adderall and symptoms of anxiety and sleep disturbance could, in some cases, suggest a bipolar disorder, particularly if there are manic or hypomanic episodes induced by the stimulant.
  • Sleep Disorder (e.g., Narcolepsy): The reversal of the sleep-wake cycle could suggest an underlying sleep disorder, though this would be less likely given the acute onset following marijuana cessation.