Cannabis Psychosis and Paranoid Schizophrenia Vinod Rai
Thacore, MRCPsych, S.R.P. Shukla, MB,BS
\s=b\ The initial clinical symptoms of 25 consecutive cases of cannabis psychosis of the paranoid type and 25 consecutive cases of paranoid schizophrenia were studied and compared, in order to delineate features that would enable a differentiation of the two conditions. It was observed that the patients with cannabis psychosis substantially differed in terms of behavioral manifestations. Most of these patients were violent and panicky and demonstrated bizzare behavior, but they possessed some insight into the nature of their illness. Schizophrenic patients manifested these disturbances and characteristics less frequently. Subjects with cannabis psychosis showed rapid ideation and flight of ideas, whereas the characteristic schizophrenic thought-disorder was found mostly in schizophrenic patients. (Arch Gen Psychiatry 33:383-386, 1976)
cannabis has been used for medicinal, rec¬ and meditational purposes since ancient times. Its euphoria-producing property is exploited during ceremonial occasions; its liberal use is particularly associ¬ ated with the Indian festival of Holi. It is obtained in three forms. Bhang, the mildest form, is the most widely used preparation. It contains up to 15% of the plant resin and is usually drunk as a beverage. It may also be con¬ sumed in the form of doughy "pills," each weighing about 30 gm, which are swallowed or taken mixed with sweets. Ganja and charas, the two other forms of cannabis, con¬ tain 15% to 25% and 25% to 40%, respectively, of the resin and are smoked with varying quantities of tobacco in earth¬ en pipes. The resin contains the active principles, the cannabinoids. However, the actual quantity of tetrahydrocannabinol (THC) in the various preparations that are used is not known. In the absence of measurements, the judgments of veteran users are relied on to assess the potency of the drug. In addition to the resin content, the
India, In reational,
Accepted
for publication March 3, 1974. From the Department of Psychiatry, King George's Medical College, Lucknow, India. Dr Thacore is now with Lakeside Hospital, Ballarat, Victoria, Australia. No reprints available.
potency of a preparation depends on such factors as culti¬ vation, storage, and mode of preparation, and consump¬ tion.1·2 The recent escalation in the use of cannabis by adoles¬ cents and young adults all over the world, including In¬ dia,3-7 has stimulated inquiry into the relationship be¬ tween the abuse of the drug and its consequences in mental health. Several workers have described toxic psychosis develop¬ ing as a result of acute cannabis intoxication.814 The toxic nature of the condition can be recognized by the confusion and amnesia that are present in addition to the paranoid symptoms. In addition, workers in India have described conditions resembling mania and dementia as manifesta¬ tions of long-term cannabis abuse.1213·15 It has also been observed, however, that a paranoid psy¬ chosis resembling paranoid schizophrenia may arise in the course of long-term abuse of cannabis.2·15·16 The psychosis is characterized by perception of the environment as hos¬ tile, delusions of persecution, and auditory and visual hal¬ lucinations occurring in a state of clear consciousness, with little disturbance in memory.2 Indeed, Varma17 could not differentiate such a psychosis from functional psy¬ choses in his large series of cases reported from North India. Dhunjibhoy13 and Chopra and Smith14 were impressed by the favorable outcome in the majority of their patients suffering from cannabis-induced psychotic states. Bow¬ ers18 has shown that patients suffering from drug-induced psychotic states score better on prognostic ratings than do the nondrug-induced psychotic patients serving as con¬ trols. It seems worthwhile therefore to attempt a differ¬ entiation of cannabis-induced psychosis from paranoid schizophrenia on the basis of initial symptoms from the viewpoint of treatment and prognosis. This study was un¬ dertaken to bring into relief the clinical features, if any, that would help delineate the two conditions. The para¬ noid condition was chosen because, in our experience, this
Downloaded From: http://archpsyc.jamanetwork.com/ by a New York University User on 05/28/2015
was
the most
common occurrence
of cannabis
which, if not differentiated, could lead diagnostic inaccuracies.
to
psychosis conceptual and
six for
more
than 12 months. No
patients.
follow-up
was
possible
for two
subjects with cannabis psychosis were all males, they compared with schizophrenic patients of the same sex who served as controls. The ages of the control subjects ranged from 16 to 50 years. When first seen, 13 patients had been ill for one to Since the
were
SUBJECTS AND METHODS
sample consisted of 25 consecutive cases each of cannabis psychosis of the paranoid type and paranoid schizophrenia. Obser¬ vations of mental status at the first examination of these patients were recorded on a standard form under the following subhead¬ The
three months, 5 for 6 to 12 months, 1 for two years, and 6 for more than five years. Three patients were treated as inpatients, while the rest received treatment as outpatients. All the patients re¬ ceived varying doses of phenothiazines, depending on the clinical condition and, in addition, nine patients received electroconvulsive therapy (ECT). Ten patients were followed up for 3 to 12 months, two for 24 months, and ten were followed up for more than two years. No follow-up was possible for three patients. The study was confined to subjects in a paranoid state to make the results of the
appearance and behavior; consciousness; orientation; mem¬ thinking; perception; affect; volition; and insight and judg¬ ment. The results were studied and compared. The patients with cannabis psychosis were defined as those in whom a clear temporal relationship between the prolonged abuse of cannabis and the development of psychosis had been observed on more than two occasions. Their ages ranged from 18 to 42 years. Except for one subject who had been using cannabis exces¬ sively for three years, all had a history of heavy indulgence for more than five years. For instance, one subject took one half to one pill of bhang every seven to ten days for nearly four years. This dose and frequency may be regarded as being within reason¬
ings:
ory;
comparison
more
meaningful.
RESULTS
The results are summarized in the Table. Behavior dif¬ fered significantly (P < .001) between the two groups of patients. In patients with cannabis psychosis, there was greater frequency of violence and odd and bizarre behav¬ ior, such as insisting to stand on a chair or sitting on the floor during the interview and smearing the body with earth to simulate the looks of a sadhu (holy man). One pa¬ tient lay prone, licking the floor. He justified his behavior by pointing out that he was only caressing the sacred dharti-mata (motherland) and asked if there was any¬ thing wrong with this action. In India, the motherland is
able limits. However, when first seen four years later, he was tak¬ ing 30 pills a day. This large daily intake of cannabis was consid¬ ered to be "heavy." Nineteen patients took only bhang, whereas six patients occasionally took charas and ganja as well. Subjects suspected of taking other psychotomimetic drugs were excluded. All patients had predominant persecutory delusions in a setting of clear sensorium. A sample of four such cases has been described in detail elsewhere.2 Nineteen subjects were inpatients and six were outpatients; five patients were followed up for one week, 12 for six months, and
Initial Symptomatology in Cannabis Psychosis and Paranoid Schizophrenia No. of Cases
Psychosis,
Cannabis Areas of Mental Behavior Odd, Bizarre Present Absent Violence Present Absent
Functioning
=
Paranoid
25
Schizophrenia, =
Significance
25
17 21
16
2=13·86, df 1,P
Thacore, MRCPsych, S.R.P. Shukla, MB,BS
\s=b\ The initial clinical symptoms of 25 consecutive cases of cannabis psychosis of the paranoid type and 25 consecutive cases of paranoid schizophrenia were studied and compared, in order to delineate features that would enable a differentiation of the two conditions. It was observed that the patients with cannabis psychosis substantially differed in terms of behavioral manifestations. Most of these patients were violent and panicky and demonstrated bizzare behavior, but they possessed some insight into the nature of their illness. Schizophrenic patients manifested these disturbances and characteristics less frequently. Subjects with cannabis psychosis showed rapid ideation and flight of ideas, whereas the characteristic schizophrenic thought-disorder was found mostly in schizophrenic patients. (Arch Gen Psychiatry 33:383-386, 1976)
cannabis has been used for medicinal, rec¬ and meditational purposes since ancient times. Its euphoria-producing property is exploited during ceremonial occasions; its liberal use is particularly associ¬ ated with the Indian festival of Holi. It is obtained in three forms. Bhang, the mildest form, is the most widely used preparation. It contains up to 15% of the plant resin and is usually drunk as a beverage. It may also be con¬ sumed in the form of doughy "pills," each weighing about 30 gm, which are swallowed or taken mixed with sweets. Ganja and charas, the two other forms of cannabis, con¬ tain 15% to 25% and 25% to 40%, respectively, of the resin and are smoked with varying quantities of tobacco in earth¬ en pipes. The resin contains the active principles, the cannabinoids. However, the actual quantity of tetrahydrocannabinol (THC) in the various preparations that are used is not known. In the absence of measurements, the judgments of veteran users are relied on to assess the potency of the drug. In addition to the resin content, the
India, In reational,
Accepted
for publication March 3, 1974. From the Department of Psychiatry, King George's Medical College, Lucknow, India. Dr Thacore is now with Lakeside Hospital, Ballarat, Victoria, Australia. No reprints available.
potency of a preparation depends on such factors as culti¬ vation, storage, and mode of preparation, and consump¬ tion.1·2 The recent escalation in the use of cannabis by adoles¬ cents and young adults all over the world, including In¬ dia,3-7 has stimulated inquiry into the relationship be¬ tween the abuse of the drug and its consequences in mental health. Several workers have described toxic psychosis develop¬ ing as a result of acute cannabis intoxication.814 The toxic nature of the condition can be recognized by the confusion and amnesia that are present in addition to the paranoid symptoms. In addition, workers in India have described conditions resembling mania and dementia as manifesta¬ tions of long-term cannabis abuse.1213·15 It has also been observed, however, that a paranoid psy¬ chosis resembling paranoid schizophrenia may arise in the course of long-term abuse of cannabis.2·15·16 The psychosis is characterized by perception of the environment as hos¬ tile, delusions of persecution, and auditory and visual hal¬ lucinations occurring in a state of clear consciousness, with little disturbance in memory.2 Indeed, Varma17 could not differentiate such a psychosis from functional psy¬ choses in his large series of cases reported from North India. Dhunjibhoy13 and Chopra and Smith14 were impressed by the favorable outcome in the majority of their patients suffering from cannabis-induced psychotic states. Bow¬ ers18 has shown that patients suffering from drug-induced psychotic states score better on prognostic ratings than do the nondrug-induced psychotic patients serving as con¬ trols. It seems worthwhile therefore to attempt a differ¬ entiation of cannabis-induced psychosis from paranoid schizophrenia on the basis of initial symptoms from the viewpoint of treatment and prognosis. This study was un¬ dertaken to bring into relief the clinical features, if any, that would help delineate the two conditions. The para¬ noid condition was chosen because, in our experience, this
Downloaded From: http://archpsyc.jamanetwork.com/ by a New York University User on 05/28/2015
was
the most
common occurrence
of cannabis
which, if not differentiated, could lead diagnostic inaccuracies.
to
psychosis conceptual and
six for
more
than 12 months. No
patients.
follow-up
was
possible
for two
subjects with cannabis psychosis were all males, they compared with schizophrenic patients of the same sex who served as controls. The ages of the control subjects ranged from 16 to 50 years. When first seen, 13 patients had been ill for one to Since the
were
SUBJECTS AND METHODS
sample consisted of 25 consecutive cases each of cannabis psychosis of the paranoid type and paranoid schizophrenia. Obser¬ vations of mental status at the first examination of these patients were recorded on a standard form under the following subhead¬ The
three months, 5 for 6 to 12 months, 1 for two years, and 6 for more than five years. Three patients were treated as inpatients, while the rest received treatment as outpatients. All the patients re¬ ceived varying doses of phenothiazines, depending on the clinical condition and, in addition, nine patients received electroconvulsive therapy (ECT). Ten patients were followed up for 3 to 12 months, two for 24 months, and ten were followed up for more than two years. No follow-up was possible for three patients. The study was confined to subjects in a paranoid state to make the results of the
appearance and behavior; consciousness; orientation; mem¬ thinking; perception; affect; volition; and insight and judg¬ ment. The results were studied and compared. The patients with cannabis psychosis were defined as those in whom a clear temporal relationship between the prolonged abuse of cannabis and the development of psychosis had been observed on more than two occasions. Their ages ranged from 18 to 42 years. Except for one subject who had been using cannabis exces¬ sively for three years, all had a history of heavy indulgence for more than five years. For instance, one subject took one half to one pill of bhang every seven to ten days for nearly four years. This dose and frequency may be regarded as being within reason¬
ings:
ory;
comparison
more
meaningful.
RESULTS
The results are summarized in the Table. Behavior dif¬ fered significantly (P < .001) between the two groups of patients. In patients with cannabis psychosis, there was greater frequency of violence and odd and bizarre behav¬ ior, such as insisting to stand on a chair or sitting on the floor during the interview and smearing the body with earth to simulate the looks of a sadhu (holy man). One pa¬ tient lay prone, licking the floor. He justified his behavior by pointing out that he was only caressing the sacred dharti-mata (motherland) and asked if there was any¬ thing wrong with this action. In India, the motherland is
able limits. However, when first seen four years later, he was tak¬ ing 30 pills a day. This large daily intake of cannabis was consid¬ ered to be "heavy." Nineteen patients took only bhang, whereas six patients occasionally took charas and ganja as well. Subjects suspected of taking other psychotomimetic drugs were excluded. All patients had predominant persecutory delusions in a setting of clear sensorium. A sample of four such cases has been described in detail elsewhere.2 Nineteen subjects were inpatients and six were outpatients; five patients were followed up for one week, 12 for six months, and
Initial Symptomatology in Cannabis Psychosis and Paranoid Schizophrenia No. of Cases
Psychosis,
Cannabis Areas of Mental Behavior Odd, Bizarre Present Absent Violence Present Absent
Functioning
=
Paranoid
25
Schizophrenia, =
Significance
25
17 21
16
2=13·86, df 1,P
