British Journal of Addiction (1991) 86, 1075-1081
RESEARCH REPORT
Cannabis psychosis following bhang ingestion HAROON RASHID CHAUDRY, HOWARD B. MOSS,' AMIR BASHIR & TAHIR SULIMAN King Edward Medical College, Mayo Hospital, Lahore, Pakistan & ' Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
Abstract The purpose of this preliminary investigation is to systematically characterize the signs and symptoms of cannabis psychosis in individuals who presented for psychiatric treatment in Pakistan after ingestion of bhang; a beverage containing cannabis. In order to control for the behavioral effects of cannabis alone, symptoms produced by bhang ingestion among non-patients consuming the same beverage were compared with those symptoms found among psychotic patients. Patients differed from controls in that a higher proportion of patients were found to be chronic users of bhang, and had a past history of psychotic episodes. Presenting symptoms of bhang-induced psychosis found in patients included grandiosity, excitement, hostility, uncooperativeness, disorientation, hallucinatory behavior and unusual thought content. Neuroleptic treatment successfully attenuated psychotic symptoms within five days of the initiation of the episode. The presenting symptoms of bhang-induced psychosis are consistent with a brief mania-like disorder with paranoid psychotic features, and cognitive dysfunction. Several etiologic hypotheses are proposed.
Although psychosis associated with cannabis use has been known to the medical community for nearly a hundred years,' there is a paucity of systematic investigations into this clinical entity. Anecdotal reports have described cannabis-induced psychiatric reactions in terms of confusional states, anxiety reactions, panic states, melancholia, hypomania, acute paranoid psychoses, acute toxic psychotic states, chronic psychotic conditions, or prolonged depcrsonalization, and amotivational conditions.'"'* Thus, there is little agreement concerning the symptoms associated with cannabis-induced psychosis. Despite the relatively high prevalence of marijuana use in the USA and other Western cultures. This investigation was supported in part by a center grant from the Natioaal Institute on Drug Abuse Center DA-05605 (Dr Moss), Correspondence should be addressed [o Howard Moss.
cannabis-associated psychoses remains a comparatively rare clinical phenomenon in the West. It has been speculated that rates of cannabis psychoses are higher among Asian cultures where cannabis is eaten rather than smoked.^ Hence, a higher prevalence of cases of cannabis psychoses may occur in India and Pakistan where it is customary to ingest cannabis, as well as to smoke various preparations of cannabis plant products. In Pakistan, cannabis-associated psychosis is frequently seen among consumers of the beverage, bhang. Bhang is one of the three general preparations of cannabis that are routinely consumed in Pakistan. Ganja consists of the flowering tops of female cannabis plants, and is usually smoked. Hashish is a resin made from the fiowering tops of the cannabis plant, and is also smoked. Bhang, however, is a beverage which is made from an infusion of cannabis leaves and fiowering tops
1075
1076
Haroon Rashid Chaudry et al.
combined with milk and nuts, and is consumed through drinking. The purpose of this preliminary investigation is to systematically characterize the symptoms of bhang-induced psychosis in individuals who present for psychiatric care in Pakistan, and to document the clinical course of this phenomenon when psychiatric treatment is undertaken. Psychiatric symptoms present among psychotic individuals are compared with those observed among bhang consumers who did not become psychotic, thus controlling for the behavioral effects of bhang ingestion alone. The resulting symptom pattern suggests that cannabis psychosis (due to bhang consumption) is a mania-like disorder with paranoid psychotic features, and cognitive dysfunction which responds to brief pharmacologic treatment.
Method Subjects
Psychiatric symptom ratings were performed on 15 male patients (mean age=25± 6.71 years) admitted as inpatients to the Lahore Brain Center, Lahore, Pakistan over a 6 month period for evaluation and treatment of problematic behavioral disturbances associated with recent consumption of bhang. All study patients were referred by general medical practitioners. No patients admitted to consuming other drugs prior to admission. In order to control
for the non-psychotogenic effects of bhang on thinking, mood, and social interaction, 10 male subjects (mean age 19 ± 1.70 years) who consumed the same bhang as the patients but did not develop a psychotic reaction also underwent BPRS ratings at the time of the patient's admission. The demographic characteristics, clinical estimates of bhang use frequency, and the frequencies of past and family psychiatric histories among patients and controls are displayed in Table 1. .
Procedures
Upon arrival at the hospital, psychiatric symptom ratings were performed by a research psychiatrist using the Brief Psychiatric Rating Scale (BPRS) of Overall & Gorham.*" This widely-used psychiatric rating scale has been used was chosen because it reliably provides a quantitative symptom profile characterizing the essential features of manifest psychopathology in a simple and parsimonious fashion. Furthermore, the BPRS is highly sensitive to changes in the psychotic condition. Following the performance of the BPRS ratings, all patients were treated with neuroleptics (specifically, haloperidol 10 to 30 mg/day^ procycHdine 5 to 10 mg/day, and chlorpromzine 100 to 300 mg/day as needed), and subsequently underwent daily BPRS ratings by the research psychiatrist. Pharmacologic treatment continued for a full week for all
Table 1. Characteristics of sample
Age in years (±s.d.) Proponion who completed high school Formally employed Clinical estimates of frequency of bhang use: First time users Occasional users* Chronic userst Past hx. of psychotic episodes* Past hx. of other psychiatric disorders Family hx. of: Major depression Schizophrenia •Fisher's exact test/i
RESEARCH REPORT
Cannabis psychosis following bhang ingestion HAROON RASHID CHAUDRY, HOWARD B. MOSS,' AMIR BASHIR & TAHIR SULIMAN King Edward Medical College, Mayo Hospital, Lahore, Pakistan & ' Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
Abstract The purpose of this preliminary investigation is to systematically characterize the signs and symptoms of cannabis psychosis in individuals who presented for psychiatric treatment in Pakistan after ingestion of bhang; a beverage containing cannabis. In order to control for the behavioral effects of cannabis alone, symptoms produced by bhang ingestion among non-patients consuming the same beverage were compared with those symptoms found among psychotic patients. Patients differed from controls in that a higher proportion of patients were found to be chronic users of bhang, and had a past history of psychotic episodes. Presenting symptoms of bhang-induced psychosis found in patients included grandiosity, excitement, hostility, uncooperativeness, disorientation, hallucinatory behavior and unusual thought content. Neuroleptic treatment successfully attenuated psychotic symptoms within five days of the initiation of the episode. The presenting symptoms of bhang-induced psychosis are consistent with a brief mania-like disorder with paranoid psychotic features, and cognitive dysfunction. Several etiologic hypotheses are proposed.
Although psychosis associated with cannabis use has been known to the medical community for nearly a hundred years,' there is a paucity of systematic investigations into this clinical entity. Anecdotal reports have described cannabis-induced psychiatric reactions in terms of confusional states, anxiety reactions, panic states, melancholia, hypomania, acute paranoid psychoses, acute toxic psychotic states, chronic psychotic conditions, or prolonged depcrsonalization, and amotivational conditions.'"'* Thus, there is little agreement concerning the symptoms associated with cannabis-induced psychosis. Despite the relatively high prevalence of marijuana use in the USA and other Western cultures. This investigation was supported in part by a center grant from the Natioaal Institute on Drug Abuse Center DA-05605 (Dr Moss), Correspondence should be addressed [o Howard Moss.
cannabis-associated psychoses remains a comparatively rare clinical phenomenon in the West. It has been speculated that rates of cannabis psychoses are higher among Asian cultures where cannabis is eaten rather than smoked.^ Hence, a higher prevalence of cases of cannabis psychoses may occur in India and Pakistan where it is customary to ingest cannabis, as well as to smoke various preparations of cannabis plant products. In Pakistan, cannabis-associated psychosis is frequently seen among consumers of the beverage, bhang. Bhang is one of the three general preparations of cannabis that are routinely consumed in Pakistan. Ganja consists of the flowering tops of female cannabis plants, and is usually smoked. Hashish is a resin made from the fiowering tops of the cannabis plant, and is also smoked. Bhang, however, is a beverage which is made from an infusion of cannabis leaves and fiowering tops
1075
1076
Haroon Rashid Chaudry et al.
combined with milk and nuts, and is consumed through drinking. The purpose of this preliminary investigation is to systematically characterize the symptoms of bhang-induced psychosis in individuals who present for psychiatric care in Pakistan, and to document the clinical course of this phenomenon when psychiatric treatment is undertaken. Psychiatric symptoms present among psychotic individuals are compared with those observed among bhang consumers who did not become psychotic, thus controlling for the behavioral effects of bhang ingestion alone. The resulting symptom pattern suggests that cannabis psychosis (due to bhang consumption) is a mania-like disorder with paranoid psychotic features, and cognitive dysfunction which responds to brief pharmacologic treatment.
Method Subjects
Psychiatric symptom ratings were performed on 15 male patients (mean age=25± 6.71 years) admitted as inpatients to the Lahore Brain Center, Lahore, Pakistan over a 6 month period for evaluation and treatment of problematic behavioral disturbances associated with recent consumption of bhang. All study patients were referred by general medical practitioners. No patients admitted to consuming other drugs prior to admission. In order to control
for the non-psychotogenic effects of bhang on thinking, mood, and social interaction, 10 male subjects (mean age 19 ± 1.70 years) who consumed the same bhang as the patients but did not develop a psychotic reaction also underwent BPRS ratings at the time of the patient's admission. The demographic characteristics, clinical estimates of bhang use frequency, and the frequencies of past and family psychiatric histories among patients and controls are displayed in Table 1. .
Procedures
Upon arrival at the hospital, psychiatric symptom ratings were performed by a research psychiatrist using the Brief Psychiatric Rating Scale (BPRS) of Overall & Gorham.*" This widely-used psychiatric rating scale has been used was chosen because it reliably provides a quantitative symptom profile characterizing the essential features of manifest psychopathology in a simple and parsimonious fashion. Furthermore, the BPRS is highly sensitive to changes in the psychotic condition. Following the performance of the BPRS ratings, all patients were treated with neuroleptics (specifically, haloperidol 10 to 30 mg/day^ procycHdine 5 to 10 mg/day, and chlorpromzine 100 to 300 mg/day as needed), and subsequently underwent daily BPRS ratings by the research psychiatrist. Pharmacologic treatment continued for a full week for all
Table 1. Characteristics of sample
Age in years (±s.d.) Proponion who completed high school Formally employed Clinical estimates of frequency of bhang use: First time users Occasional users* Chronic userst Past hx. of psychotic episodes* Past hx. of other psychiatric disorders Family hx. of: Major depression Schizophrenia •Fisher's exact test/i
