role of cannabis in psychiatric disturbance

ROLE OF CANNABIS IN PSYCHIATRIC DISTURBANCE

Frank Knight

Department of Psychiatry University of the West Indies

and Cornwall Regional Hospital Montego Bay I

Jamaica, West Indies

INTRODUCTION

This paper is based on two controlled studies of cannabis users in Ja- maica 1, conducted between 1970 and 1972 and on several years of clinical observation before and after these studies were performed. It will present an account of some patterns of psychiatric illness and the relationship that cannabis may bear to them.

Jamaica is an island of slightly less than two million people, whose life-style is tropical and essentially Western. Jamaica is unusual for a Western country, in that cannabis is extensively cultivated, and its export in bulk has brought in a significant amount of foreign money, mainly from North America. The country is unusual, too, in that cannabis consumption has been endemic for decades. One survey based on an indirect inquiry method of 78 nonhospital- ized working-class males over the age of 15 concluded that 36 of them smoked more than once per day, while another five smoked less than once per day. The plant is believed to have been introduced to the country from India by inden- tured laborers about 100 years ago. The use of the drug in the form of ganja (the flowering tips and the young leaves of the plant) is widespread among the laboring classes. It is usually smoked but may be brewed as tea, and in this form it is commonly used by adults, and even given to young infants, for medicinal purposes. Laborers claim that it helps them to concentrate and to work harder.

In recent years, the use of ganja has spread to the middle classes, university students, and high school adolescents. In these three groups, its use generally reflects the pattern of use by comparable groups in North America.

Jamaica is also the home of the Rastafarian movement, whose adherents may be recognized by their freely growing locks of unshorn hair, their cultural use of ganja (“the holy weed of wisdom”), their belief in the godhead of the late Emperor Haile Selassie, and their view of Africa as the home to which all black people should return.“ Members of this semireligious cult sometimes live in communities separate from the general population. This feature of their life-style, together with their dietary rules and their use of the Old Testament, makes their doctrine and way of life attractive to rebellious adolescents who may or may not also have borderline psychotic illness.

These features of Jamaican life and culture, in addition to its virtual freedom from hard drug users, make it the ideal location to study the effects of cannabis, because, although illegal, the drug is freely available at low cost, has wide cultural use, and is the only mind-altering or sedative drug used by a large sector of the population.

Despite its popularity among some of the middle class, there is a general attitude of disapproval and resistance among them toward the use of ganja,

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Knight: Psychiatric Disturbance 65

which is associated in their minds with Rastafarians, teenage dropouts, crime, and madness. The association with madness is accepted in the island’s one large psychiatric hospital, where the diagnosis of “ganja psychosis” has long had recognition among the staff.

This is a useful background against which to examine what relationships may exist between psychiatric illness and cannabis usage.

STUDIES OF CANNABIS USERS IN JAMAICA

Studies of Long-Term Use

A study of 30 chronic male cannabis users in Jamaica versus 30 matched controls did not reveal any active psychiatric disturbance or organic deficit, nor did it demonstrate any significant difference between the groups as measured by physical, physiologic, and psychometric tests or electroencephalographic exami- nati0ns.l Chronic use was described as daily consumption for at least 7 years. Another study in Jamaica of 16 chronic smokers and 10 controls, and subse- quently repeated with 28 subjects, looked at physiologic and psychologic fun- tioning and found no chronic effect in either area that could be attributed to cannabis usage.* In both of these studies, the subjects were required to abstain from the drug during the testing period. In the first study, the subjects, aged between 23 and 53 years, were admitted to the hospital for 1 week; in the second study, the subjects were required to not be “high” (i.e., not to have used cannabis in the 4 hr prior to the test).

Cfinical Survey of Mental Hospital Patients

A survey of 106 of 112 consecutive male admissions to Bellevue Psychiatric Hospital in Kingston showed that 26 of these patients were heavy ganja smokers (i.e., at least once per day), while another seven were light users (less than once per day). The authors’ main theme is a suggestion that cannabis may be a cheaper alternative to alcohol for the poorer class of people. In addition to this suggestion, they conclude that there is no evidence to implicate cannabis use as a factor ‘that contributes to psychiatric illness. However, the study lacks details of case histories or of diagnoses or symptoms and bases its findings on the patients’ responses to questionnaires and the authors’ clinical impression [“Notre experience de deux ann&s A Bellevue nous donne A penser que cela (ganja as a contributory factor in admission) est rarement le cas”]. It does not appear that there was enough evidence in this study on which to base this conclusion.

Clinical Findings in Psychiatric Patients in Urban and Rural General Hospitals

At the University Hospital of the West Indies, of 74 males admitted to the psychiatric unit over a 12-month period in 1972, 29 (39%) gave a history of some past usage of cannabis. Ten of these patients (13.5% of the male admissions) who had smoked it within days or weeks of admission were diagnosed as

66 Annals New York Academy of Sciences

‘‘ganja psychosis,” and a new diagnosis of “marijuana-modified mania” was coined for four others after their clinical picture changed from schizophreniform illness on admission to classic hypomania after a few days in the h ~ s p i t a l . ~

At another general hospital (see TABLE 1 ) ,G Cornwall Regional Hospital in Montego Bay, a total of 269 patients were admitted to the psychiatric unit in the 12 months that ended in March 1975, with 66 patients (24.2%) having a history of cannabis use, 35 of them (13%) within 2 months of admission (see TABLE 1) . The functional psychoses, which were comprised of 223 patients, constituted the largest group, with 54 patients (24.2%) having a history of cannabis use.

The diagnoses given refer to diagnosis either on discharge or after several months of follow-up, by which time premorbid personality and family history could be taken into account and weighed against the acute clinical picture at the time of inpatient treatment. Schizophreniform characteristics were considered to be such features as blunted affect, primary delusional ideas, ideas of

TABLE 1

NUMBER OF PATIENTS WITH A HISTORY OF CANNABIS USE: CORNWALL REGIONAL HOSPITAL, APRIL 1974 TO MARCH 1975

Recent Past Cannabis History

Use Only of Total Number (last 2 Cannabis Who Used

Diagnosis Number months) Use Cannabis

Hypomanic reaction 76 9 5 14 (18.4%) Depressive reaction 59 1 6 7 (11.9%) Schizophreniform reaction 88 25 8 33 (37.5%) Total (functional psychoses) 223 35 19 54 (24.2%) Other diagnoses 46 7 5 12 (26.1%) Total 269 42 24 66 (24.2%)

reference, and alienation of thought. The term “schizophreniform reaction” (see below) was adhered to because it was thought that for a diagnosis of true schizophrenia to be made, the observer had to be certain that the clinical picture was not being influenced by cannabis use, and this certainly was not always possible once a habitual or occasional cannabis user was discharged from inpatient care.

At three other rural general hospitals over the same period of tine, cannabis usage was thought to be a contributory factor in 1 1 of 51 (Falmouth Hospital), seven of 18 (Lucea Hospital), and 39 of 75 (Savanna-la-Mar Hospital) patients admitted for treatment of schizophreniform reactiom6

Findings on the Pathoplastic Eflect of Cannabis

The description “marijuana-modified mania” was first applied to a par- ticular clinical sequence when four male patients were admitted to the psychiatric unit of the University Hospital, Kingston over a period of time, with what


at first appeared to be a schizophrenic reaction5 The common features of their reactions are described as follows: All patients were men aged 20-31. All had, for several years prior to their illness, used marijuana in moderate amounts without mishap. All displayed initial symptoms of a hypomanic nature, fol- lowed by a marked increase in marijuana usage. At the time of admission, an initial diagnosis of paranoid schizophrenia was made in three of the four patients based on the presence of withdrawal, persecutory delusions, auditory hallucinations, and disorder of thought. No patient displayed mood elevation at this stage, nor was there any evidence of toxic psychosis (all were normally orientated and lacked signs of clouding of consciousness). Within 3-4 days of admission, all developed symptoms and signs of manic or hypomanic illness. In addition, two patients had family histories of manic depressive psychosis, one suffered a subsequent episode of mania, and one developed a depressive illness.

The conclusion drawn was that “these patients were suffering from a primary affective illness (mania or hypomania) and that excessive use of marihuana was symptomatic of their illness (analogous to the excessive use of alcohol by some manic patients) .” These cases were seen as being distinguish- able from mania with a paranoid flavor.

It commonly happens that, in certain stages mania exhibits features of paranoia and delusional thinking which are so prominent that a diagnosis of schizophrenia is in fact made. In a report on a longitudinal study on 20 manic patients Carlson and Goodwin (7) have emphasized the unreliability of cross-sectional observation in making a diagnosis. We believe that in the cases reported here marihuana was responsible not only for producing the schizophreniform picture, but also for making the episodes mimic schizophrenia as closely as they did by introducing features of withdrawn behaviour, echolalia, echopraxia, blunted affect, fragmentation of thought, and third person hal- lucinatory voices which generally are not encountered in manic illness that takes on a paranoid appearance.

Since these cases have been described, at least nine others that would fit into the same classification have been documented.6

In contrast to these cases that show the modifying effect of cannabis on hypomania are seven cases cited from the Cornwall Regional Hospital. These seven persons, of 59 with a depressive reaction, were diagnosed as having “cannabis involvement.” This feature is thought to have modified the depressive picture, so that it included strong paranoid feelings and, in some instances, an aggressive excitability. (It is interesting to compare these features with the findings in depressed patients who, while being given tetrahydrocannabinol to help their symptoms, developed paranoid ideas of persecution.8)

Individual Case Studies

One interesting case deserves special mention as showing only hypomanic features after cannabis use:

A 29-year-old unmarried male technician of rural working-class background, with a reputation for sobriety and an easygoing manner, was observed to be behaving oddly at work for a few days. One morning, he suddenly became short-tempered and assertive, threatening his boss verbally and disrupting the work of all of his colleagues. He was brought by force to the casualty depart-


ment of the local hospital, where he presented with a typical hypomanic picture of distractibility, pressure of talk, and punning. Paranoid features were notably absent. He was persuaded to accept admission into a hospital, where he was treated with oral chlorpromazine, up to 800 mg/24 hr, and lithium carbonate, 250 mg four times daily. He improved rapidly within 3 days, although his discharge home was delayed for another 3 days to allow for full reassessment.

This man confessed to having started smoking cannabis 4 weeks previously, taking up to two “spliffs” daily. (A “spliff’ or “skliff’ is roughly the equivalent of a North American “joint.”) He had done it partly for the experience and partly to help him forget the financial problems he anticipated with his forth- coming marriage. Long before his discharge from the hospital, he had regained full insight, was embarrassed by the incident, anxious that his fiancte should not be told the real cause, and certain that he would never use cannabis again.

Another interesting case is described:

A boy 16 years old experienced a “bad trip” on the first and only occasion that he smoked cannabis. Subsequent to that occasion, he had gone away to school but had to return home because of a series of experiences of unreality related to himself and to the passage of time. He also began to experience what was probably a form of sleep paralysis: near morning, he would dream that he was in his own bed and his own room (which he was) but was unable to move or call for help. Invariably, before the dream became distressing, he would have the experience of falling asleep, then would wake up in reality. This young man’s symptoms went on for 3 years with periods of relapses and recovery, often with depressive episodes, before he started to remain consistently well.

EXPLANATION OF TERMS USED

Ganja Psychosis

The clinical features generally accepted by psychiatrists and nursing staff in psychiatric units in Jamaica as justifying a patient being placed into this category are a history of disturbed, sometimes aggressive, behavior after several days of unaccustomed cannabis use (either in persons who had not used it previously or had used it in smaller amounts) ; schizophrenic features, such as blunted affect, withdrawal, and bewilderment; other schizophrenic features, such as hallucinations and paranoid ideation; and the continuation of symptoms for a period of several weeks after the drug is presumed to have been eliminated from the body.

Schizophreniform Reaction

This term has come into use more and more as a provisional diagnosis at the Cornwall Regional Hospital, where it is considered that such a high proportion (37.5 % ) of patients admitted with symptoms of schizophrenia owe much of their symptomatology to cannabis. Sometimes for months after discharge, and despite the use of injectable depot fluphenazine, it is not possible to be certain that it is schizophrenia and not the continued use of cannabis that is responsible for the persistence of psychotic features.


It is convenient at this point to refer to a very useful classification suggested by Negrete 9 for adverse reactions to cannabis, which conforms to most of the syndromes seen in Jamaica. He recommends the adoption of severe intoxication, pathologic intoxication, acute cannabis psychoses, subacute and chronic cannabis psychoses, and residual conditions for the sake of clarity and uni- formity in describing syndromes attributable to cannabis. The first of these classes is recognized in Jamaica as the response of a normal individual to an unusually large dose of cannabis, generally the result of a stronger than normal sample of the drug. No treatment is sought or given, and the subject who has been having hallucinations and a feeling of floating returns to normal when the concentration of the drug in the bloodstream falls. The second category (“panic and short-lasting paranoid states with fear of police arrests . . ., fear of death, of losing one’s mind . . ., depersonalization . . . with consequent panic”) is the well-known “ganja reaction” seen by casualty officers in hospitals all over the island. In our experience, the duration is less than 24 hr: the subject is usually given an intramuscular injection of about 200 mg of chlorpromazine and is allowed to sleep off his intoxication overnight.

Negrete’s “acute cannabis psychosis” corresponds to the Jamaican ‘6ganja psychosis,” in which it is considered that the use of the drug has acted as a triggering mechanism in an individual who is vulnerable or susceptible to schizophrenic disorder. The psychotic reaction continues and requires treatment in its own right, much the same as may occur if it has been triggered off by obstetric confinement or a surgical operation. Our experience coincides with that of Murphy and of Bromberg, as quoted by N e g ~ e t e , ~ that many of these cases are eventually diagnosed as schizophrenia.

Subacute and chronic cannabis psychosis as described in this classification matches approximately a picture most readily recognized in some Jamaican vagrants who bear the outward signs of the Rastafarian cult. In common with the Rastafarians, they sport the “dreadlocks” style of unshorn hair and use cannabis when it is available. But, unlike the true brethren, they wander the streets in a state of personal untidiness, often manifesting thought disorder and paranoid ideas if one stops to engage them in conversation. They do not really fit into the mainstream of Rastafarians. This author feels that they represent cases of schizoid personality or borderline psychosis who have been attracted to the Rastafarian cult and who, though they may gain some psychologic relief by use of cannabis, are pushed over into and kept in a state of mild psychosis. Some of them, no doubt, are true schizophrenics whose symptoms and bizarre behavior would be present even without their resorting to cannabis.

Into the category of “residual conditions,” Negrete puts the amotivational syndrome. This category approximates a class of person in Jamaica who proves most difficult to manage. They are often represented by teenage rebels or dropouts from eminently respectable professional and middle-class families who adopt the Rastafarian style of speech (a characteristic of which is reference to one’s self as “I man” or “I and I”). Possibly because of their middle-class background, and despite the change in language, hair style, and diet, their involvement with the doctrine of Rastafarianism is often more of a flirtation than a true commitment, leading one colleague to dub them “Rastoid” 10 (as contrasted with those who are truly Rastafarian). Our experience agrees with Negrete’s view that their attitudes and behavior are related more to their changed beliefs than to cannabis usage. Their intelligence and convictions make them stubborn when they are not intoxicated, and when they do smoke, they


become even more intransigent. The other residual condition included by Negrete, flashbacks, has been seen in Jamaica in several adolescents, occurring in them for many months after smoking cannabis. One of these cases was discussed above in the individual case studies.

GENERAL DISCUSSION

Planned studies have failed to reveal any evidence that cannabis is responsible for psychologic changes in long-term users. It is conventional and accept- able to refer to such studies when drawing conclusions about the effects of cannabis. However, the studies cited sought to identify permanent effects of cannabis use in subjects who were not under the acute influence of the drug at the time of testing. These subjects are really in a different category from those in whom clinical observation incriminates cannabis as a cause of psychiatric illness and adverse psychologic effects.

In any event, there will always be a discrepancy between what is observed during normal clinical activity and reported retrospectively, on the one hand, and what is found in planned controlled studies, on the other. For clinical!y reported episodes, the investigator is at a disadvantage in not knowing the potency of the cannabis used and in depending on the biased reports of the subject, his friends, and family. But the reporting of a large number of cases with a strong similarity in their histories would seem to go some way toward compensating for the absence of controls.

In considering the carefully controlled studies on long-term use, the question could arise as to the status of these users: whether, in fact, the samples may be biased from the beginning because the subjects chosen could be seen as the survivors, as it were, of many years of cannabis use.

Even controlled studies of acute consumption of cannabis may not present as unbiased a conclusion as we might think. For the sake of argument, it must be possible to subject 100 persons to the type of stress that is believed to lead to thyrotoxicosis or diabetes, without, in fact, producing a single case of either of these conditions. Such an approach neglects the factor of constitutional liability, which is accepted as operating in the causation of psychosomatic illness and which can be presumed to be present in the case of “ganja psychosis,” to explain why, of the many persons known to expose themselves to the drug, only a small proportion suffers any serious adverse effects.

CONCLUSIONS

Despite the unlikelihood of being able to prove an association between cannabis usage and psychiatric disturbance, this author hopes that the examples presented will favor a reacceptance of the role of clinical observation in strengthening the validity of clinical theories. It is to be hoped that instead of a preoccupation as to whether cannabis is involved in the causation of psychiatric illness, more attention will be focused on the ways in which the distur- bances are caused and on how they may be modified by the presence of the drug.

SUMMARY

Clinical observation suggests that cannabis is implicated in some types of psychiatric disturbance. A record of admissions to two urban and four rural


hospitals in Jamaica is examined along with details of individual cases. One- third of male admissions to the psychiatric hospital have used cannabis. Of 74 males admitted to another psychiatric service over a 12-month period, 29 had used cannabis. Ten of these patients were diagnosed as “ganja psychosis,” and four others were classified as “marijuana-modified mania.” At another psychiatric service, 54 of 223 admissions (24.2% ) for functional psychosis presented with cannabis usage as a contributory factor. These 54 patients included 14 and seven cases of hypomanic and depressive reactions, respectively. At three other rural general hospitals, psychiatric admissions for psychosis showed 11 of 51, seven of 18, and 39 of 75 patients, respectively, in whom cannabis was considered directly responsible. These findings lend support to the idea of causation of illness or modification of existing illness. The negative findings of controlled studies in the same country are not inconsistent. A suggested classification for adverse reactions to cannabis offered by one author is recommended, because it is in accord with common local clinical experience.

REFERENCES

1. BEAUBRUN, M. H. & F. KNIGHT. 1973. Psychiatric assessment of 30 chronic users of cannabis and 30 matched controls. Amer. J. Psychiat. 130: 309-311.

2. BOWMAN, M. & R. 0. PIHL. 1973. Psychological effects of chronic heavy use. A controlled study of intellectual functioning in chronic users of high potency cannabis. Psychopharmacologia 29: 159-170.

3. PRINCE, R., R. GREENFIELD & J. MARRIOTT. 1972. Cannabis ou alcool? Obser- vations sur la consommation de ces substances en Jamaique. Bull. Stupkfiants 24: 1.

4. SMITH, M. G., R. AUGIER & R. NETTLEFORD. 1960. The Rastafari movement in Kingston, Jamaica. Institute of Social and Economic Research. Kingston, Jamaica.

5. HARDING, T. & F. KNIGHT. 1973. Marihuana-modified mania. Arch. Gen. Psy- chiat. 29: 635-637.

6. KNIGHT, F. 1976. Report from the Department of Psychiatry, Cornwall Re- gional Hospital. Montego Bay, Jamaica.

7. CARLSON, G. A. & F. K. GOODWIN. 1973. The stages of mania: a longitudinal analysis of the manic episode. Arch. Gen. Psychiat. 28: 221-228.

8. KOTIN, J., R. M. POST & F. K. GOODWIN. 1973. Delta-9-tetra-hydroannabinol in depressed patients. Arch. Gen. Psychiat. 2 8 345-348.

9. NEGRETE, J. C. 1973. Psychological adverse effects of cannabis smoking: a tentative classification. Can. Med. Ass. J. 108 195-202.

10. ALLEN, E. A. 1971. Personal communication.

role of cannabis in psychiatric disturbance

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