Cannabis Psychosis: a case report

British Journal of Addiction (1986) 81, 139-142

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The Editor welcomes all letters whether they are short case reports, preliminary reports of research, discussion or comments on papers published in the journal Letters commenting on a paper may be sent to the authors of that paper so that their reply may appear in the same issue. There is no rigid limit to length but in general the shorter the letter the better the chance of publication. Authors should follow the same guidelines given for the preparation and submission of articles on the inside back cover of each issue, especially that regarding tables or illustrations. Letters should be signed by all authors.

herself to the Emergency Clinic and was seen by Cannabis Psychosis: a case report the night duty psychiatrist. On examination she From Lynne Drummond (Maudsley Hospital, was overactive, perplexed, tearful and exhibiting London) SIR—Cannabis has been reported to cause an acute thought disorder, but was orientated in time, place short-lived psychotic illness in some patients and person. She expressed persecutory ideas that (Weil, 1970; Meyer, 1975; Rottanburg et al, she was being tortured by people who had broken 1982). This issue, however, remains controversial. into her flat, recorded songs with messages for her I would like to report a case of a 26-year-old onto her tape recorder, watched her with binocuCaucasian woman who appears to present with lars and 'bugged' her home. She also had ideas of acute psychotic episodes related to cannabis con- reference concerning a library book which was a biography of a famous painter, which she believed sumption. The patient had visited the Maudsley Emer- was telling her life story. She said she had left her gency Clinic in 1980 and in 1984. On these husband that night and would refuse to return occasions she presented with mild depression and home. Overnight admission was arranged and a anxiety in the context of complaints of marital urinary drug screen was taken. This was found to difficulties and she showed no evidence of any be strongly positive for cannabis, positive for psychotic features. Her anxiety symptoms settled benzodiazepines and negative for morphine, methrapidly with treatment. She gave no family history adone, amphetamines and barbiturates. of psychiatric disorder. Her personal history was The next morning she appeared more cheerful unremarkable, apart from some learning difficul- and less distressed. She was talkative and circumloties at school and having left prematurely at the cutory but had no evidence of formal thought age of 15 years due to a pregnancy. At the age of 16 disorder. Although she still had ideas of reference years she married the father of her child but this and persecutory ideas, she was less concerned by relationship had been turbulent since then. these. Therefore she was allowed to leave hospital She gave a history of having frequently smoked and was asked to return for follow-up in 4 days cannabis since 1982, always in the company of her time. No medication was given. When she returned, she appeared cheerful and husband. Together they would smoke a street weight of approximately -J ounce (4 g) of cannabis had no evidence of any psychotic symptoms. She per week. After smoking cannabis, she had noticed remained separated from her husband and had that she became anxious and frightened of her found herself accommodation. She remembered husband's friends and, on occasions, had believed her strange ideas which had caused her to present at the hospital and thought these were a result of that they were laughing and talking about her. At the end of January 1985 she re-referred her imagination. She admitted smoking cannabis 139

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Letters to the Editor

approximately a day before coming to hospital and felt her agitated presentation might be related to this as well as her excitement at having left her husband. During February she was seen weekly for follow-up. On her next two attendances she remained well and had no further abnormal beliefs or experiences. During this period she remained separated from her husband and denied any use of cannabis. At the end of February she arrived for her fourth appointment. She had returned to live with her husband 5 days previously and admitted smoking cannabis regularly since then. She appeared suspicious and anxious and expressed a number of persecutory ideas. Once again she complained that people had broken into her flat, recorded onto her tape recorder, 'bugged' her flat and urinated on her bed. She believed that the hospital had colluded with her persecutors in losing her case record on her previous attendance. Her urinary drug screen on this occasion was again strongly positive for cannabis, weakly positive for benzodiazepines and negative for amphetamines, morphine, methadone and barbiturates. The duty doctor prescribed trifluoperazine and asked her to return in a week. However, she failed to attend this appointment and, due to uncertainty about her address, this was not pursued further. Although the information about this lady is limited, it would appear that she suffered from two short-lived psychotic episodes in clear consciousness following consumption of cannabis. Many workers have emphasized the importance of chronic continuous use of cannabis (Tart, 1970) or ingestion of a large dose to produce psychotic phenomena (Klonoff, 1973). The case history given suggests a more moderate use of cannabis precipitating psychotic episodes.

TART, C . T . (1970) Marijuana intoxication: common experiences. Nature, 226, pp. 701-704. WEIL, A. T. (1970) Adverse reactions to marijuana, classification and suggested treatment. New England Journal of Medicine, 282, pp. 997-1000.

Prolonged Depersonalization Following Cannabis Abuse From M. S. Keshaven & W. A. Lishman (Institute of Psychiatry, London) SIR—There is evidence, both from experimental studies in normal volunteers', and from clinical observations in this country^ and elsewhere^ that acute intoxication with cannabis results in depersonalization and derealization experiences. There is, however, only one report of patients experiencing prolonged depersonalization following cannabis abuse*. We report two patients who presented with this picture, one in this country and the other by one of us (MSK) in India.

Case 1

A 20-year-old unemployed man was referred for advice on account of persistent feelings of unreality lasting for some 10 months. He had no past or family history of mental illness, and described himself as a friendly, fun-loving person. He had left school at the age of 16 and since then had been smoking marihuana regularly, mostly in company of his friends. He had not abused alcohol or other drugs. After stopping cannabis on his own in March 1984 he was well for about a month, then insidiously developed a 'flu-like' illness with chills, nausea and anorexia, for about 2 weeks. One day in May he suddenly felt 'as if he did not belong', and as if everything around was 'unreal' and 'meaningless'. The experiences were unpleasant and frightening, but he felt numbed in his emotions. He did not feel depressed, but lacked energy and had LYNNE M . DRUMMOND initial insomnia. He experienced occasional 'flashSenior Registrar, backs' reminiscent of his previous cannabis trips, Maudsley Hospital, London, SES 8AF, U.K. viz. vision and hearing becoming clearer and brighter; intense feelings of 'belongingness' and 'feeling intensely into the meaning of things'. KLONOFF, H . (1973) Strategy and tactics of marijuana Sometimes he felt as if 'colours were spilling over research, Canadian Medical Association Journal, 108, pp. from one eye to the other' when he closed one eye 145-150. MEYER, R.E. (1975) Psychiatric consequences of mariju- and opened the other. ana use: the state of the evidence, in: TINKENBERG, J. R. When seen by us, he was already much im(Ed.) Marijuana and Health Hazards (New York, proved, but admitted to occasionally experiencing Academic Press). transient feelings of unreality. He was reassured RoTTANBURG, D., BEN-ARIE, O . , ROBINS, A. H. & TEGGIN, A. (1982) Cannabis-associated psychosis with hypo- about the good prognosis and advised to refrain manic features. Lancet, 2, pp. 1364-6. from cannabis. He did not return for follow-up.