Marijuana and adverse psychotic reactions

Sections

Introduction
Historical review
The cannabis plant
Motivation for cannabis usage
Hemp psychosis
Two hundred case studies
Discussion
Appendix

Details

Author: Gurbakhsh S. CHOPRA
Pages: 15 to 22
Creation Date: 1971/01/01

Marijuana and adverse psychotic reactions

Evaluation of different factors involved

M.D. Gurbakhsh S. CHOPRA Drug Addiction Clinic, Hastings, Calcutta, 22, India

Introduction

Over the past few years a new problem has arisen all over the world - that of the abuse of psychedelics such as LSD and marijuana. International news and communication media have featured debates, discussions and articles on these drugs. Advocates allege that hallucinogens or psychedelics are of use in art, music and religious exercises. At the same time, the hazards of these drugs have been pointed out and debated by many persons. This study examines the controversy surrounding the role of Cannabis sativa as a cause or precipitant of psychotic reactions.

Historical review

In order to better understand the effects, both psychological and physical, of cannabis on the human mind, it is of interest to review briefly the historical background of the cannabis plant. The drug has been used as a psychedelic from ancient times. The various appellations assigned to the plant in ancient literature give an indication of its effects.

Referring to ancient Aryan literature, cannabis is mentioned by various names in the Atharva Veda 2000 B.C. It is called "indracana ", meaning god's food, "bhanga ", meaning destroyer and "vijaya ", meaning victory and suggesting a mood of relaxation. In later works such as the Rajnirghantu, 1400 B.C., hemp is called "ajaya ", or unconquered, "virapatra ", heroic-leaved, "ganja" or "capta ", light-hearted, "anada", joy, and "harshani ", the rejoicer. The psychedelic and psychomimetic effects of the drug were well known to Indians of that time. Comparatively recent writings such as the Hindu Meteria Medicas, Bhavaparaka and Rajavallbha, A.D. 1600, describe the drug as one producing infatuation, intoxication, vital energy, correction of phlegmatic humour, and as an elixir vitae.

In Arabic and Persian literature, there are frequent references to the plant and to its discovery. It is related that Sheikh Jafar Shirazi, a monk of the order of Haider, lived alone on a mountain where he had established a monastery. After having lived in such seclusion, he returned one day with an air of joy and gaiety. Upon being questioned, Jafar stated that in order to appease hunger and thirst, he had gathered and eaten leaves of a particular plant growing in the area, and had experienced feelings of exhilaration. He then led his companions to the spot where all chewed the leaves and were similarly affected. The knowledge of the peculiar properties of the leaves gradually became known to the followers of Shirazi, and a decoction prepared by soaking the leaves in wine became the favourite drink of the Haider sect. Since that time, the Islamic world has used the drug as a means of supposedly opening the gates of earthly paradise," Jannat ". The Arab's favourite was "hashish ", a name which gave rise to the sect of Haschins or Hashnavis, from which it has been suggested the word "assasin" is derived. * Hassan, who founded the sect, and his followers committed heinous crimes under the hallucinations of the drug, with the belief that if they died they would go to heaven, whereas, if they lived they would enjoy sexual experiences with beautiful women, "hoors ".

There are many other references in history, to cannabis and its powers. For instance, Herodotus mentions the Scythians smoking cannabis in order to induce a state of excitement. Hemp has frequently been used for mental disease. Such use was brought to the attention of the Europeans by Sylvesto-de-lacy and Rouyer, who were members of Napoleon's expeditionary forces in Egypt.

* This story has been reported in a different manner by some writers and seriously questioned by others.

The cannabis plant

Cannabis preparations can be divided into roughly three grades of potency. At the lowest level are marijuana and bhang. These consist of the dried mature leaves and flowering tops of male and female plants, both wild and cultivated. When smoked, this preparation is called marijuana. When steeped in hot water and drunk as a beverage, it is referred to as bhang. It may also be prepared in the form of a sweetmeat. Of higher potency is ganja, obtained from the small upper leaves and flowering tops of the female plant. It is approximately three times as potent as bhang and marijuana. In India ganja is usually smoked in pipes. The most powerful preparations are charas (chira) or hashish. They consist of the pure resin of the flowering tops and leaves of the female plant. Charas and hashish are approximately five to eight times as potent as bhang and marijuana. Like ganja, they too are usually smoked in a pipe.

Crude preparations like marijuana, "kif", "dagga ", are available in the rest of the world. They are roughly equivalent in potency to bhang, although they vary according to the country of origin. They are approximately one fifth to one eighth as potent as hashish. Cannabis is sometimes mixed with other drugs to potentiate its effects. A recent example found in Mexico and the United States, is the boiling of marijuana with acetone in order to extract an oil which is mixed with hashish and rolled into pellets.

Motivation for cannabis usage

The motivation for drug usage and the surrounding environment, are significant factors as regards psychotic states. Various individuals list different reasons for using cannabis. First of all, it is widely used as a substitute for alcohol or opium. The low cost of hemp and the fact that there are practically no withdrawal symptoms, make it an attractive substitute. In under-developed countries such as India, the use of cannabis drugs by certain sectors of the population can be compared to the consumption of alcohol in the West. A distinction should thus be drawn between occasional, regular and moderate users, and those who indulge in excess. The latter category of users are obviously more prone to adverse psychotic reactions. The users in the United States and other Western nations, belong mostly to the first two categories. This partly explains the infrequency of psychotic reactions among users in these countries. Like alcohol, excessive cannabis use can be attributed to pre-existing problems of the individual. This is supported by a Moroccan saying which states that "You are a kif addict before you smoke your first pipe ". The highest percentage of excessive hemp users are from the unemployed and low-income classes.

Secondly, hemp was and is used for religious purposes. Cannabis has played a central role in the religions of Africa and South America, as well as in India. In Africa, there are instances when an entire village has exhibited spells of madness after indiscriminate indulgence in "dagga ". In India the drug is commonly abused by religious mendicants in places of worship and in" takyas " of Muslim fakirs. Visitors come in order to indulge in passing the ganja or "chillum" pipe. They smoke until they are dazed and then pass the pipe on. Most of these individuals are again uneducated, lower-income groups and normally are greatly inhibited. These situations provide them with a company and environment willing to accept them. The motive is to achieve "aram ", a feeling of rest and relaxation, accompanied by a mild state of intoxication.

Cannabis is also used by persons in the various arts. Supposedly it enables one to perform more creatively. It is likely that the drug enhances the emotional aspects of the creative process. However, there is no proof that it helps in technical performance.

Persons often attempt to relieve fatigue, monotony, and boredom by using cannabis. It is especially used for this purpose by the labouring and working classes in urban areas. The drug induces a feeling of restfulness and mild euphoria. Such use is not frequently excessive and is similar to the use of marijuana in Western society.

There are in addition, miscellaneous other uses for cannabis. It has been believed by some that hemp enhances sexual enjoyment. However, there is some evidence that it actually depresses sexual desire. There are rare instances when the drug has been used supposedly as an inducement to homicidal violence. The followers of Hassan, mentioned earlier, were such an example. However, the general action of cannabis is to quiet and stupefy the individual so that there is little tendency to violence.

Environmental and sociological factors often contribute to the desire to use hemp. These factors have become especially important in the last two decades in countries like India where rapid changes in life style are taking place. Modern technology, industrialization, and rapid transportation increase the daily pressure upon the individual. In addition, the influx of the population to urban areas has brought about vast changes in traditional modes of living. In the intermingling of cultures, races and persons in the cities, an individual may have difficulty adjusting, and may experience social alienation. Such persons are susceptible to the attractions of cannabis, which offers an easy and inexpensive method of relaxation. Persons who suffer the most stress and strain from the new environment, are usually the most prone to adverse reactions from using cannabis.

Hemp psychosis

Hemp psychosis as observed by workers in India and Africa has not been generally reported by Western Observers. The milder preparations of cannabis used in the West partially explain this comparative absence of such psychosis. In India there has always been a popular belief that prolonged and excessive use of these drugs leads to certain forms of mental disorder and crimes of a violent nature. The conclusions of the Indian Hemp Drug Commission in 1894 ( [ 12] ) dealt with this popular belief. The Commission considered that" Moderate use of these drugs produced no injurious effects except in persons with specially marked neurotic diathesis. Excessive use indicates and intensifies mental instability.

Moderate use produces no moral injury whatsoever." Ewens ( [ 11] ) found that there was a direct relationship between the excessive use of hemp and the form of mental disease classified as "toxic insanity". Robertson-Milne ( [ 18 ] ) and Dhunjibhoy ( [ 10 ] ) came to similar conclusions. In previous studies ( [ 5 ] , [ 6 ] , [ 7 ] , [ 8 ] ), the author has discussed the relationship between hemp habituation and mental disease and crime. It became evident in these studies that excessive indulgence in cannabis drugs by unstable and susceptible individuals was apt to produce states of confusion characterized by hallucinations, delusions and disorientation. Prolonged excessive use also appeared to lead to the possible development of toxic psychosis.

Two hundred case studies

Evidence for this study was based upon the examination of 200 cannabis dependants studied for a period of five years. Taken into consideration were age of onset, education, socio-economic status, dosage, motivation, psychological and general health, signs of malnutrition, type of personality, and other relevant data. The design and execution of this study represents a compromise between the niceties of research methods and the limitations imposed by the realities of the situation. While considerable care was taken in the design, the standardization, and the subsequent analysis of the following data, it was affected by factors over which there was no control. The patients were seen usually during acute, and frequently agitated states. The amnesia and garrulousness in some cases, made the examination difficult. Often, information could not be obtained until the patient had regained his memory. Some difficulties were imposed because the patients were often examined in unfamiliar surroundings. Over-all, the information about antisocial and criminal behaviour are likely to be under-estimates rather than over-estimates.

Over a period of five years (1963-1968), 1,800 patients were seen in the field and in the Drug Addiction Clinic in Calcutta. Of these, 200 (11.1%) exhibited psychotic symptoms following the use of cannabis preparations, and are the subjects of this investigation. Of these subjects, 95% were male. The medium age was 31 years, and the range was from 18 to 60 years. Of the patients, 70% were single, while 30% were either married, widowed or separated; 50% were Hindu, 30% were Moslem, 12% were Sikh, and the remaining 87% were members of other religions. The higher percentage of Hindus and Moslems can be explained by the general population breakdown and by the use of the drug by some Hindu and Moslem religious mendicants. As to the general condition of health, 65 % were in good health with no signs of anaemia or malnutrition. There were no other significant physical problems bearing upon this study.

The majority (65%) were uneducated while 23.5% of the persons had received a primary school education. Adverse reactions were more common in the uneducated group. A different situation exists in the United States where many marijuana users are educated youth from college campuses. With regard to occupation, persons in lower income groups were more susceptible to adverse reactions. This is once again unlike the United States and other Western countries, where many users are from the middle class. Table I shows the occupational breakdown and monthly salary of the 200 patients.

TABLE I

 

Monthly income

 

Occupation

Rs.

$

Number

Percentage

Religious mendicants
Nil
  80 40.0
Manual labourers
60 10 40 20.0
Cultivators
80 12 35 17.5
Skilled labourers
100 14 25 12.5
Clerks
150 19 10 5.0
Auto drivers
200 25 7 3.5
Students
Nil
  3 1.5

The intensity of the adverse reaction also varied according to the preparation used. In Table II, it can be seen that adverse reactions were more frequent in the cases of stronger preparations.

TABLE II

 

Incidence of psychotic reaction

Preparation

Average daily dose at time of psychotic reaction (grammes)

No.

Percentage

Charas or hashish
5 94 47
Ganja
10 74 37
Bhang
6 32 16

Varying kinds of personal problems and frustrations were also involved in the study of these patients. Of the patients, 27 % had demonstrated tentative or definite evidence of neurotic disturbances at an early age. However, at the time that the psychotic episode occurred, all except two appeared normal and stable. Of the patients, 30% exhibited various personality problems, while others were bordering on psychosis. Only in 5% of the cases had there been a history of psychosis prior to cannabis abuse. Of the patients, 57% stated that they consumed alcohol occasionally while 10% utilized cannabis as a substitute for alcohol. Similarly, 16% of the patients used it instead of opium. Of the patients, 18% had a criminal history of conviction. In addition, 13% admitted stealing, while 20% stated they committed acts of violence against their associates upon the slightest provocation. However, such individuals were prone to violent acts, independent of the drug. The use of cannabis merely accentuated this tendency.

Most of the subjects presented themselves, or were brought to the clinic within forty-eight hours after onset of adverse psychotic reactions. Only a few (5 %) presented themselves at a later time. These few persons were those who had previous psychotic problems.

The subjects of the study were grouped into three main categories. Group I consisted of 68 (37%) individuals. They were healthy with little or no personality problems, and had no history of mental disorder or neurosis. An invariable element was the history of their use of drugs. The patients' symptoms were so similar and uniform as to give a reasonable supposition of a definite effect following a definite cause. The symptoms were of a mental nature, similating acute toxic psychosis. There were no other concomitant factors beyond the use of the drug. This eliminated the possibility of the toxic psychosis resulting from other causes.

Group II was composed of 122 (58%) patients and formed the bulk of the study. Most of them were on the threshold of psychosis. They included psycopaths, delinquents, hypochondriacs, and those suffering from varying degrees of personality frustrations and conflicts. A large percentage of these persons also showed signs of schizophrenia and paranoia, and many were ambulatory psychotics. States of confusion were present in the early stages, thus making it sometimes difficult to separate persons in this group from those in Group I. The duration of the reaction was fairly short. After the toxic reactions of the drug had disappeared, the symptoms of the pre-existing psychosis became manifest in greater intensity. Schizophrenic and paranoid reactions predominated during the later stages. After withdrawal of the drug, the patients reverted to their pre-existing psychotic tendencies and ambulatory psychosis.

Group III included 10 (5 %) individuals with a history of psychosis. Most of them experienced acute intoxication. In the case of these individuals, the symptoms of cannabis psychosis were superimposed on pre-existing psychotic states. Even after the drug was withdrawn they ran a chronic course of their original psychosis. The use of the drug was either coincidental or a symptom of the pre-existing psychosis. Schizophrenic and acute confusional reactions were more common in these cases. This may be due to the fact that because of their preexisting psychotic states, they had been leading lives of marginal existence and therefore reacted more intensely to the drug. Their balance between outer and inner reality was already very precarious and under stress, they were more susceptible to cannabis and tended to become mentally disorganized and fragmented under its influence.

A correlation between the personalities, symptoms, intensity of psychotic episodes, and their duration and prognosis is shown in Table III.

It thus transpires that the most common reaction which could be solely attributed to cannabis, or associated with it, is the confusional state which often develops into toxic psychosis as seen in these 200 patients. An example which illustrates such development is the case of J. M. *

J. M. was a 30-year-old brass worker with no history of hereditary mental disease and no addiction other than bhang. All inquiries failed to elicit any probable cause of psychosis other than use of the drug. He was under my treatment from 1 October to 1 December 1967. On admission he was found to be suffering from acute brain syndrome, seemingly due to the drinking of bhang. (He later told me that he had been in the habit of drinking 180 grains daily.) Upon withdrawal of the drug, he was completely cured and was discharged. He did well and secured a job until trouble of a trivial nature occurred, and he again reverted to the use of bhang. Immediately, a fresh attack of a violent nature occurred, for which he was brought again to the clinic. He displayed the usual symptoms of garrulity, constant laughing, incoherent speech, restlessness, violence, insomnia, flushed face, and congested conjunctiva. He recovered in about thirty days and remained under observation for a year. During this period he led a normal life working in an office. Like most of these patients, upon recovery he had no recollection of his condition until much later.

There were several others, including those who suffered relapses, who attributed their psychotic condition to the abuse of cannabis. On the other hand, persons who after being cured, abstained from the use of cannabis, remained sane, even after several years. There were of course, other relevant factors such as pre-existing psychosis, environment and personality. However, this study indicated that the excessive use of cannabis was a definite agent responsible for inducing a psychotic state. In many cases, persons appeared normal and stable until they abused cannabis, at which time the tendency for psychosis became evident. In a few cases, patients stated that their condition was attributable to a single dose of bhang, ganja or charas, usually administered by a fakir or sadhu. According to these persons, they had been induced to take a large amount of the drug which brought about a state of" nasha" or intoxication. They remembered nothing until they found themselves in the clinic or in the custody of the police.

* See appendix for brief histories of 22 of the patients included in this study.

TABLE III

Personality

Symptoms

Duration

Intensity

Prognosis

No.(%)

Group I
Usually stable Normal or Para-Normal
Euphoria; excitation; hallucinations; delusions; delirium (rare); negative and resistant attitude; restlessness; alternate laughing and weeping; depressive state; easily responsive; irresponsible when excited; ataxia absent; acute confusional psychosis; paranoid distress; depersonalization
Temporary Few hours Few days
Subacute
90 % recovery with-out treatment, when drug is with-drawn
68(37)
Group II
Usually weak and Unstable Disorganized and schizophrenic per- sonalities
Mental disorientation; anxiety regarding heart or respiratory failure; strong morbid delusions; schizophrenic symptoms; depression; melancholic; agitation; garrulous; acute maniacal and paranoid reactions; insomnia; rarely violent
Few days to weeks May continue for a few months with frequent relapses
May be subacute
Recovery relapses frequent Partial remission in schizophrenics
122(58)
Borderline psychotic states
         
Group III
Disorganized with previous psychosis Inhibitory impulses in psychopaths and and schizophrenics
Apparently calm; talkative; easily satisfied; lazy; indifferent about future; lack of interest in family; desire to smoke; violent reaction to small provocations; intermittent remissions; in some cases, inorganic psychosis with or without dementia
Cannot be predicted Remissions and relapses common
Mild
Poor Recovery rate very low
10(5)
Most ambulatory schizophrenics in chronic condition Strong disaffiliation
 
May end in chronic psychotic state
     

A diversity of reactions was noted in each case. It was thus not possible to attribute a particular symptom, or categorize the episodes under specific diagnostic entities. However, the common and frequent symptoms which most of these individuals presented, were confusional states amounting to toxic psychosis (acute brain syndrome), hallucinations, delusions,schizophrenia, paranoia, amnesia and depersonalization. Many suffered from restlessness, garrulousness, feelings of dread or feelings of well-being or exulation. The significant physical changes observed were suffused face, blood-shot eyes, and conjunctival congestion. The episodes were usually short and varied from a few hours to a few days. Upon withdrawal of the drug, the patient almost invariably recovered in a few days or few weeks.

After prolonged and continuous cannabis abuse, chronic psychotoxic states followed in certain cases. Symptoms varied from a state of mild intoxication, to a pleasant, semi-delirious condition, to a state of seeming ecstasy. Indifference to surroundings was often displayed. Mild delirium sometimes developed, and sometimes led to reckless acts of violence which were often not remembered upon recovery. Because of daily, excessive indulgence, these individuals often had insufficient time for total recovery from intoxication, and thus passed into a toxic state resulting in acute brain syndrome. However, upon complete and sustained withdrawal of the drug, most of these patients also recovered.

In none of the 200 cases studied, were fatal effects caused by cannabis abuse. However, an enormous dose of charas may bring about death. In this connexion the author recalls two prisoners in the Central Jail in Lahore in 1928. The prisoners had been previously addicted to charas, but had been forced to forego the habit upon incarceration. They suddenly obtained a large amount of the drug and consumed larger doses than they had been accustomed to taking. The effect was a rapid onset of coma, vomiting, strenuous breathing, marked congestion of conjunctiva, and coldness, followed by collapse. The post-mortem examination showed no positive signs except marked congestion of the internal viscera.

No one can dispute the possibility that the disorder of the cannabis user who displays psychosis, may have arisen in other ways. In these cases, the use of the drug may be a symptom of the pre-existing psychosis. It may be further possible that as with alcohol, cannabis abuse may be the first symptom of loss of control in persons in whom psychosis is commencing. However, in many of the cases, no factor except the abuse of cannabis seemed to be responsible for the psychosis.

A summation of the psychotic disorders diagnosed in these 200 cases, is given in Table IV. It should be noted that acute mental disorders following the abuse of cannabis, far outnumber chronic disorders.

TABLE IV

Diagnosis

No.

Percentage

(A) Acute disorders:
   
(1) Acute confusional reactions
62 31.0
(2) Schizophrenic reactions
53 26.5
(3) Paranoid reactions
35 17.5
(4) Depressive reactions
19 9.5
(5) Acute brain syndrome
21 10.5
(B) Chronic disorders:
   
(1) Chronic schizophrenia
8 4.0
(2) Organic psychosis with dementia
2 1.0

Discussion

Mental derangement following the use of psychotoxic drugs like Cannabis sativa, is nothing but an abnormal reaction on the part of cerebral cells whose physiological activities are either held in abeyance, or partially or totally disorganized. This perverted activity releases the control centres, thus allowing the senses to be more easily influenced by external stimuli. These reactions may occur in one or more parts of the central nervous system. Cannabis, when absorbed into the system, does not add any new element to the brain. It only removes this higher control and excites the pre-existing trend of mental aberrations, if any.

All types of psychotic reactions resulting from cannabis intoxication are therefore characterized by certain common general symptoms. These are, excitation of thought processes, a sense of intoxication, and incoherent ideas and actions. However, these symptoms vary in each individual according to personality, mood, education, judgement and motivation. The same dose of cannabis does not produce similar effects in all individuals, and those persons with pre-existing psychotic and neurotic tendencies appear to be more easily affected than normal healthy individuals. The individual's psychotic threshold also plays a part in determining the effects.

According to Delay ( [ 9] ), psychodysleptic drugs stimulate intellectual activity, but the positive reactions to which they give rise are really negative reactions resulting from the release of control by the higher centres. Cannabis therefore disturbs the physiological thinking process. This may give rise to delirium, distortion of reality and sense of judgement, and further confusional states may follow delusions and hallucinations caused by the drug. This may ultimately lead to depersonalization and a dream-like state of fantasy. This action is actually psychomimetic in nature.

This study indicates then, that there is a relationship between marijuana and psychotic episodes which may be influenced by the basic personality of the individual using the drug. It seems that a particular symptom complex resulting from cannabis intoxication, is dependent upon various factors comprising personality, education, religion, socio-economic status and motivation. The psychotic episodes are self-induced, exogenous in nature, making it difficult at times to differentiate from endogenous psychosis, especially in the case of persons with pre-existing psychotic disorders. Finally, the drugs appear to act mainly through action upon the higher control centres which behave in an abnormal manner under the influence of the drug, without any stimulating or depressive effects on the lower centres.

Appendix

Brief extracts from histories of 22 cases where psychosis was attributed to, or associated with cannabis abuse.

  1. R. L., age 35, was a mendicant with no family history of psychosis. He spent all money obtained from charity and earnings on bhang and charas, and frequently went without food for want of money. Unstable, violent, abusive, filthy, incoherent, he later became morose. Upon withdrawal of the drug, the symptoms disappeared in about three weeks. He has abstained from these drugs for the last three years and is normal. There is no other cause which could be responsible for his psychosis except cannabis abuse.

  2. T. S., age 35, had smoked charas for nine years. There was no family history of psychosis. Intractably incoherent, filthy, garrulous, he had no idea of time or space, and had delusions of having been robbed of all his money, and of females coming around him. He had no idea of his condition, and recovered completely in three weeks upon withdrawal of the drug.

  3. H. C., age 38. There was no family history of psychosis or drug addiction. He confessed that he had been in the habit of using cannabis drugs to excess (daily dose of charas, 160 grains).He constantly asked for more charas, was-very irritable, always fighting, violent, abusive, had fits of excitement and delusions that his brother had robbed him of his belongings. He had been a sadhu and also had delusions of a religious nature. He had amnesia about his condition, and settled down in about three months.

Marijuana and adverse psychotic reactions 21

  1. S. S., age 33. He spoke coherently, giving a clear account of having become temporarily unconscious (" behosh "), as a result of taking large doses of bhang. In that condition he had injured his wife with an axe. He was also in the habit of drinking moderate amounts of alcohol (8 oz. daily) in the company of others. He suffered from depression, was voraciously hungry, and sometimes refused to reply to questions. These symptoms disappeared within forty-eight hours after withdrawal of the drug. He is now apparently healthy and normal.

  2. P. S., age 22. He suffered from symptoms of acute brain syndrome, following excessive use of both charas and bhang for about one week. Occasionally excited, irritable, he suffered loss of memory and had sexual hallucinations and delusions of being a Raja. He recovered after three months. There were no other attributable factors except cannabis abuse.

  3. S. S., age 37, a school teacher. Out of curiosity he took 15 grains of bhang in the company of his brother who consumed 360 grains. He had never taken the drug before. While his brother felt happy, exhilarated, and high, he felt dizzy and experienced a sinking sensation and felt that he was going to die. There was an inner struggle between his will and feelings. His face was flushed, he had an excessively high heartbeat, and upon examination, he was found to be suffering from nervous collapse. He was given chlorpromazine intramuscularly. He remained agitated and depressed for four days, after which recovery followed. His brother enjoyed the euphoria of the drug for six hours and did not suffer from any adverse effects.

  4. R. S., age 39, a clerk. He was invited to smoke ganja by a fakir and smoked more than he had ever before. He felt that he could not hear or follow the conversation of others. He also felt that he could not talk coherently. He was brought to the clinic in a confused state, where he was given 25 milligrams of chlorpromazine hydrochloride (thoranzine). Sleep followed, and he awoke the next morning depressed, agitated, pale, disinterested in his surroundings, and feeling that he was going mad. He was then given two capsules of chlordiazepoxide (Librium 20 mg), psychotherapy, and assured that nothing was wrong with him. Recovery followed in the next three days.

  5. S. K., age 30, a carpenter. He was in the daily habit of smoking ganja, when he suddenly felt sick and confused, could not follow the talk of others, lost his memory, felt voraciously hungry, could not recognize or talk to his family members, and felt as if he was crawling on the wall. He was given 25 mg. of Largactil by mouth, after which he fell asleep. He awoke, suffering from severe headache, but recovered in the next twenty-four hours.

  6. M. D., age 25, a riksha puller. He had a history of frequent indulgence in large doses of bhang and charas. After an excessive use of charas he threw his sister's child from the roof of his house, injuring her seriously. Noisy, restless, filthy, incoherent, he had no idea of what he had done. He recovered after two months and remained normal for one year, when he again obtained some charas. Within a few hours after smoking the drug, he displayed the previous symptoms of acute toxic psychosis. He again recovered within four months. There was no previous history of psychosis.

  7. B. M., age 28, a Brahman. He had a history of frequent excessive indulgence in bhang and charas. He suffered from acute brain syndrome for one month, after which he recovered.

  8. M. D., age 52, a Brahman whose mother was insane. He was addicted to charas and could not understand simple questions. He was talkative, filthy, aggressive, incoherent, depressed, and suffered from amnesia, sexual hallucinations, and delusions of grandeur. Recovery followed in about one year.

  9. G. R., age 50, a beggar. He was insane for a year following excessive use of cannabis and opium. His speech was incoherent, he had a staggering gait, was violent and had delusions of communion with God, and of having great possessions. It was not possible to test his memory as his speech was incoherent. After two years of treatment and observation, he was still in this state, and continues to wander in the streets of Calcutta. This is probably a case of superimposed psychosis upon a pre-existing condition.

  10. P. R., age 39, a coolie. He had a history of excessive indulgence in bhang, but no history of psychosis. He suffered from confusional states following large and frequent doses of charas. There was a perceptible loss of memory. He had a previous history of four such attacks after large doses of cannabis. He recovered in about three weeks.

  11. D. V., age 25, a student. He was maniacally violent and attributed his condition to charas smoking. There was no family history of psychosis. He recovered within a few days after withdrawal of the drug.

  12. T. R., age 45, a beggar. He was a heavy charas smoker, while his mother used ganja excessively. For three years, attacks of acute toxic psychosis had followed very large doses of the drug. He did willful damage to property of other persons, became violent, and was subject to fits during charas intoxication. Chronic psychosis developed. This was obviously a case of a pre-existing psychosis aggravated by cannabis abuse. He showed little or no improvement.

  13. P. S. C., age 42, an artisan. He had a history of excessive use of all forms of cannabis drugs, but no previous history of psychosis. He was suffering from acute toxic psychosis, loss of memory, and dizziness. Previously, he had suffered four such attacks. He recovered after the drug was withdrawn.

  14. D. R., age 47, a beggar. He had a history of attacks following large doses of ganja. He was incoherent, noisy, talkative, and hungry. He had sexual hallucinations and delusions of grandeur. His memory could not be tested because of incoherent speech. Upon recovery, which followed in a few weeks, he admitted taking one tola (180 grains) of charas which had led to the present psychotic state.

  15. S. D. R., age 46, a shopkeeper. He had been taking 45 grains of charas every day for the past one year. He suddenly felt intensely intoxicated. This feeling was followed by depersonalization, loss of memory, insomnia, a reckless attitude towards life and surroundings, and incoherent speech. Except for heavy smoking of ganja and charas, there was no attributable cause for his condition. He recovered in about one week.

  16. S. D. R., age 49, a manual labourer. He admitted that he was in the habit of taking bhang in the form of sweets for over one year. He suddenly lost his memory, became destructive and violent, incoherent in speech, had a staggering gait, and lost his sense of time and space. Upon withdrawal of the drug, he recovered in forty-eight hours.

  17. K. L., age 39, a coolie. He was caught trying to burn the house of his neighbour, which he explained he was doing upon the orders of God Almighty. He was restless, reckless, grinning, giggling, and had no idea of his condition. Upon recovery of his memory, he admitted taking an unusually large dose of bhang (180 grains). He used bhang daily, but the dosage varied from day to day, as it depended upon his daily earnings. He had a history of three previous attacks. He recovered upon withholding of the drug.

  18. S. M., a teacher. He had been smoking ganja for nine months and had then given it up for a few months. During a visit to a friend, he suddenly began smoking ganja again. He experienced hallucinogenic effects, developed signs of psychotic decompensation, and was brought to the clinic suffering from acute paranoid schizophrenia. He was given phenothiazines in large doses, and psychotherapy, and showed remarkable improvement. He recovered completely in about three weeks and was discharged.

  19. G. S. D., age 51, a bus driver. He was a known ambulatory schizophrenic with no history of previous cannabis use. He stated that he was induced by his friends to smoke ganja on the festive occasion of Dewali, after which he felt elated and happy at first, and then confused and dizzy. This was followed by acute depression and a state of anxiety. On administration of psychotherapy, he soon regained his confidence and the normalcy of his feelings towards his surroundings. He completely recovered within one week.

References

001

Asuni, T., "Socio-psychiatric problems of cannabis in Nigeria ", Bulletin on Narcotics , 1964, 16 (2), 17, 18.

002

Bhaskaran, K., Personal communication, Mental Disease Hospital Kankee, India, 1968.

003

Blum, R. H., "Mind-altering drugs and dangerous behaviour: dangerous drugs ", Task Force, Narcotics and Drug Abuse. Washington D.C., President's Commission on Law Enforcement and Administration of Justice, 1967, pp. 21-39.

004

Carstairs, G. M., "Daru and bhang: cultural factors in choice of intoxicant", Quarterly Journal Studies on Alcohol , 15, pp. 220-237, 1954.

005

Chopra, R. N., Chopra, G. S., and Chopra, I. C., "Cannabis sativa in relation to mental diseases and crime in India ", Indian Jour. Med. Res ., 30, 1942.

006

Chopra, G. S., and Chopra, P. S., "Studies on 300 Indian drug addicts with special reference to psycho-sociological aspects, etiology, and treatment ", Bulletin on Narcotics , 17 (2), June 1965.

007

Chopra, G. S., "Man and marijuana", The International Jour. of the Addictions , 4 (2), June 1969, pp. 215-247.

008

Chopra, R. N., and Chopra, G. S., "The present position of hemp drug addiction in India ", Indian Jour. Med. Res ., Memoirs 31, 1939, pp. 1-119.

009

Delay, Jean, Bulletin on Narcotics , 19 (1), Jan. 1967.

010

Dhunjibhoy, J. E., Transactions, Far Eastern Association of Tropical Medicine, 7th Cong., Calcutta, 1, 1927, p. 400.

011

Ewens, G. F. W., Indian Medical Gazette , 39, 1904, p. 401.

012

Indian Hemp Drug Commission Report, 1893-94.

013

Isbell, H. et. al., Psychopharmacologia, vol. II, 1967, p. 184.

014

Lambo, T. A., "Medical and social problems of drug addiction in West Africa ", Bulletin on Narcotics , 17 (1), 1965, pp. 3-14.

015

Lewin, Louis, Phantastica: Narcotic and Stimulating Drugs, Their Use and Abuse , E. P. Dutton & Co., Inc., New York, 1964.

016

McGlothin, W. H., Toward a Rational View of Marijuana, 1967.

017

McGlothin, W. H., "Social and cultural aspects of hallucinogens ", paper presented at the International Symposium on the Psychodysleptics, Laval University, Quebec City, Canada, Sept. 16-19, 1968.

018

Robertson-Milne, C. J., Indian Medical Gazette , 41, p. 129, 1906.

019

Schechel, Carl L., et. al., Science, June 1968, 160, pp. 1467-68