A retrospective study of symptom patterns of cannabis-induced psychosis

Imade AGT, Ebie JC. A retrospective study of symptom patterns ofcannabisinduced psychosis. Acta Psychiatr Scand 1991: 83: 134-136. The aim of this study was to find out whether there are any similarities between cannabis psychosis on the one hand and schizophrenia and mania on the other, and to delineate any consistency in the pattern of clinical symptoms of cannabis psychosis. Relevant data were collected from patients case-notes depicting biographical information and the frequencies of mental symptoms. Age and duration in hospital agreed between the 3 groups. Although several significant differences were recorded in the distribution ofmental symptoms, it was not possible to demonstrate a consistent pattern of symptoms typical of cannabis psychosis.

A. G. T. Imade, J. C. Ebie2
Department of Mental Health, College of Medical Sciences, Deceased, University of Benin Teaching Hospital, Benin City, Nigeria

Key words: cannabis: psychosis, schizophrenia; mania A.G. Tosan Imade, Department of Mental Health, College of Medical Science, University of Benin, Benin City, Nigeria Accepted for publication September 1, 1 9 9 0

Some clinicians in Africa and Asia have used cannabis-induced psychosis (cannabis psychosis) to describe a form of psychosis said to be schizophrenialike and resulting from the use of cannabis. The features include paranoid ideas, delusions, depersonalization and excitement (1,2). Some authors, for example, theorize that cannabis can act as a direct aetiological factor or as a precipitant of this form of psychosis (2-6). The implication of such a theory is two-fold; first, that the patients manifest psychotic features on injection or smoking cannabis, and second, that the features are similar to those of schizophrenia. On the contrary, cannabis has been isolated as a probable independent risk factor for schizophrenia (7), and in other studies, as representing a form of endogenous schizophrenia, since no difference has been found between cannabis psychosis and endogenous schizophrenia (8, 9). Cannabis psychosis has gained recognition as a nosological entity (10, 11). The ICD-9 and DSM-I11 categorize cannabis psychosis as either a form of drug dependence or induced organic mental disorder. The diagnostic criteria include intoxication, which is marked by delusional disorder. Such delusions are caused by the recent ingestion of cannabis and persist for only 2 h. There is also impairment of social and occupational functioning. Such impairment and reactions to the substance vary according to the socioeconomic class, personality and attitude of the users (12). For example, members of lower socioeconomic status and students take cannabis to make them feel bold and tough, and those of higher status perceive cannabis as a relaxer and hence take it, as it makes them calm.
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Some clinicians still argue that clinical and empirical observation indicate the persistence of some psychotic features (including delusions) in cannabis psychosis that are distinguishable from the transient delusional state present in substance abuse or substance-induced organic mental disorders. In view of the controversy, it is necessary to compare the clinical features of cannabis psychosis on the one hand and mania and schizophrenia on the other to establish any difference or similarity or any consistency in the pattern of clinical features among cannabis psychosis patients.
Material and methods Subjects

The subjects consisted of 272 psychotic patients (65% men and 35% women) hospitalized at the University of Benin Teaching Hospital (UBTH) Psychiatric Ward between 1979 and 1984. The subjects were clinically diagnosed as suffering from toxic psychosis (cannabis abuse), mania (including mania, hypomania and excitement state) or schizophrenia. Seventy of the patients (67 men and 3 women) were diagnosed as having toxic psychosis (cannabis abuse). They were said to have abused cannabis before admission into psychiatric ward. The mean age was 22.9 years (range 13-40). Fifty-eight were single and 2 married. Twenty-one were unemployed or housewives, 29 students, 12 civil servants, 2 skilled labourers and 6 unskilled labourers. A mean of 42 d in hospital was recorded during their first admission. The manic group consisted of 39 patients, 20 men and 19 women (mean age of 29.6 years; range

Cannabis-induced psychosis

15-59). Nineteen were single, 18 married, 1 separated and l divorced. Nine were unemployed or housewives, 9 students, 13 civil servants, 4 skilled labourers and 5 unskilled labourers. The patients spent a mean of 48 d on their first admission. Of the 163 schizophrenics, 55% were men and 45% women. The mean age was 27.9 years (range 12-59 years). Sixty-eight percent were single, 3 1% married and 2% divorced; 26% were either unemployed or housewives, 32 % skilled labourers, 7% unskilled labourers and 6 % professionals. The duration of stay was 49 d during the first admission.
Procedure

Table 2. Pair-wise differences between the 3 diagnostic groups Significant differences Symptoms Content of thought Forms of thought Auditory hallucination Visual hallucination Insomnia Mood Volition Distractibility Anxiety Memory, short term Memory, long term Dreams Orientation for person 1 vs2

1 vs3 X X X X

2 vs 3

X X X

X X X X

X X X

The data were obtained from patients case-notes in the Medical Records Library, which were reviewed by a psychiatrist to confirm earlier diagnosis. To qualify for inclusion, a single diagnostic criterion was maintained. Biographical information on sex, age, marital status, occupation, number of times admitted to the psychiatric ward and duration in hospital were recorded. The symptoms were grouped into 25 categories in the area of content and form of thought,
Table 1. Symptom patterns of the 3 diagnostic groups Cannabis psychosis n = 70 Symptoms Content of thought Forms of thought Auditory hallucination Visual hallucination Insomnia Affect Psychomotor movement Mood Volition Relationship to the external world/movements Lack of insight Aggression Distractibility Anxiety Attention and concentration Memory, short term Memory, long term Money spending Picking rubbish Appearance Abnormal behaviour Refusing to eat Intelligence Micturition Libido Redness of eye Orientation time Orientation place Orientation person Dreams Schizophrenia n = 167

1 = cannabis psychosis: 2 = mania and hypomania; 3 = schizophrenia.

Mania n = 39

P
(chi-square, df = 2)

auditory and visual hallucinations, insomnia, affect, psychomotor activity, mood, volition, relationship to the external world and other forms of movements. Others were lack of insight, aggression, distractibility, anxiety, attention and concentration ; money spending, picking rubbish, appearance, refusing to eat, intelligence, micturition, libido, redness of the eye, orientation, dreams and other abnormal behaviours .
Results

(%I
40 30 27 21 44 19 19 47 9 39 27 70 0 64 30 9 9 3 4 21 41 7 1 1 1 3 7 9 7 0

%
56 60 33 33 72 13 13 92 3 21 44 59 13 41 41 23 3 8 3 26 23 8 5 0 3 0 5 3 3 8

(%I
62 75 61 39 46 20 14 59 1 36 29 56 5 19 40 25 16 5 4 25 37 10 1 0 4 0 14 5 0 0

0.05 0.05 0.05 0.05 0.05 0.05 0.05 -

0.05 0.05 0.05 0.05

-

There were no significant differences of duration in hospital or age, although the mean age of patients diagnosed as having cannabis psychosis was lower than that of the other 2 groups. Furthermore, more men abused cannabis than women and the abusers were mainly unemployed and students (12). The distribution of symptoms in the 3 groups of patients is shown in Table 1. Chi-square analysis of each symptom shows significant differences in 10 of the 25 symptoms. Table 2 shows the pair-wise significant differences. The schizophrenics were significantly different (P < 0.05, one-tad df = 1) from the cannabis psychosis on content and form of thought, auditory and visual hallucination, distractibility, anxiety, short-term memory and orientation for person. Mania was significantly different from cannabis psychosis on form and content of thought, insomnia, mood, distractibility, anxiety short-term memory and dreams. Other results show that auditory hallucination, insomnia, mood, anxiety and dreams differentiate schizophrenia from mania.
Discussion

0.05 0.05

No similarity was observed between cannabis psychosis and schizophrenia in the major psychotic
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Imade & Ebie

symptoms. Similarity was also absent when the cannabis psychosis was compared with mania. On the contrary, the results confirm the clinical criteria for the diagnosis of schizophrenia and mania as shown in the proportions of the major psychotic symptoms that distinguish these two disorders (10, 11). Abnormalities of affect, psychomotor activity, lack of insight, aggression, appearance and other forms of nonpsychotic abnormal behaviours were found to occur frequently among all 3 groups. Interestingly, aggression, anxiety and abnormal behaviour, which feature prominently for the cannabis psychosis, tend to be related to violence, panic and bizarre behaviour (1). But the occurrence of these symptoms was not statistically different from those of schizophrenia and mania and hence they cannot be used as sole criteria in diagnosing cannabis psychosis as a separate diagnostic entity. However, we observed that symptoms in the area of volition, orientation for person and anxiety distinguished cannabis psychosis from the other 2 groups. However, the occurrence of the disturbance of volition and orientation for person was too low to typify cardinal symptoms of cannabis psychosis, whereas anxiety occurred often. Although major psychotic symptoms occurred in cannabis psychosis, the pattern and distribution of scores was not unique to cannabis psychosis. We were therefore unable to discover any consistency of symptoms among the cannabis psychosis that could lead to its classification as an independent diagnostic category different from schizophrenia. In the main, cannabis may be a possible risk factor in the development of schizophrenia, as reported elsewhere (7).

Conclusion

It was impossible to establish any criteria for an independent classification of cannabis psychosis, since symptoms recorded were either shared in high proportion with the other 2 groups or they occurred too seldom to make such an independent diagnosis.
References
VR. 1. THACORE Bang psychosis. Br J Psychiatry 1973: 123: 225-229. 2. NEGRETEJC. Psychological adverse effects of cannabis smoking. A tentative classification. CMBJ 1973: 108: 195-196. 3. LAMBO Medical and social problems of drug addiction TA. in West Africa with special emphasis on psychiatric aspects. Bull Narcotics 1960: 17 (I): 3. 4. BOROFFKA Mental illness and Indian hemp in Lagos, A. Nigeria. East Afr J Med 1966: 53: 377. 5. BENABUD Psychopathological aspects of the cannabis A. situation in Morocco: statistical data for 1956. Bull Narcotics 1956: 9: 1-16. 6. CHOPRA GS. Man and marihuana. Int J Addict 1969. I . ANDREASSON, ALLEBECK ENGSTROM RYBERG S P, A, U. Cannabis and schizophrenia. Lancet 1987: 1483-1486. K-L. Fortschr Neurol Psychiatr 1983: 51: 8. TASCHNER 235-248. 9. SIJUWOLA Comparative study of psychosis associated OA. with cannabis. West Afr J Med 1986: 5: 271-276. 10. International Classification of Diseases. 9th edn. Geneva: World Health Organization, 1975. 11. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd edn. Washington, DC: APA, 1980. 12. MARKD, IMADE GT. The effect of ethnicity and education on attitudes towards mental illness in southern Nigeria. SOC Int J Psychiatry 1980: 26: 101-107.

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