Psychotic Episodes

What has been referred to as psychotic episodes occurred in 9 subjects, 7 men and 2 women. A description of the happenings in each instance is given. (2)

(2) Throughout this section fictitious initials are used to avoid any disclosure of the subjects' identities.

A.V. Male. Non-user. Given 4 cc. of marihuana concentrate. About three hours later he became restless, tremulous, agitated, fearful of harmful effects, suspicious of examiners. For short periods he was euphoric. At one time he had visual hallucinations of figures making gestures suggesting harm. He talked continuously, mainly expressing fear. His answers to questions were delayed but intelligent.

W.P. Male. Occasional user. Given 3 cc., repeated two hours later. At first there was a euphoric state; later he became resistant and negativistic. He showed antagonism to the examiner, demanding to be left alone. He vomited twice. Throughout he was highly excited and talked to himself. The effects in general resembled those seen in a maniacal state. He returned to his normal state in about three hours after the second dose.

F.D. Male. Occasional user. Given 4 cc. Five hours later he became confused, disoriented and slow in answering questions. There were periods of elation and depression with laughter and weeping. The effects passed off in six hours.

R.W. Male. Non-user. Given 5 cc. Three hours later he became disoriented with continued talkativeness and rapid shifting of thought. He had fits of laughter and weeping, grandiose ideas, some paranoid trends. He answered questions clearly but without perseveration. He returned to normal after six hours.

I.N. Female. Occasional user. Also heroin addict for many years. Given 8 cc. Three hours later she became confused and anxious with periods of laughing and weeping. There were several short episodes resembling hysterical attacks and dyspnea, pallor and rapid pulse during which she felt that she was dying and screamed for the doctor and for a priest. Throughout, her response to questioning was intelligent but delayed. There was a return to her normal state in three hours.

E.C. Male. Non-user. Given 6 cc. Two hours later he developed a marked state of anxiety accompanied by a sensation of difficulty in breathing. This began during a basal metabolism test. In the Sanborn equipment used there is a nose clip occluding nasal breathing and a rubber mouthpiece through which the air is inspired and expired. During the test the subject became confused, panicky and disoriented as to time. The anxiety over breathing continued for four hours but could be interrupted by distraction. He was then given 4 cc. more. The breathing difficulty lasted five hours more. The condition here had features seen in claustrophobia. Before the episode, the subject had taken marihuana on five occasions in 2, 4, 5, 5, and 2 cc. dosage, without any symptoms of respiratory distress. However, after the episode he took marihuana on three occasions in 2, 5, and 6 cc. dosage and each time the respiratory symptoms occurred. A certain degree of nervousness was present but there was no mental confusion. The subject realized that there was no physical obstruction to his breathing and had learned that by concentrating his thought on other lines he could keep his respiratory difficulties in abeyance and would not suffer from real anxiety. Smoking up to as many as thirteen marihuana cigarettes did not bring about the respiratory effect. It appeared then that the respiratory symptoms were precipitated by the wearing of the apparatus while under the influence of marihuana, and through suggestibility there resulted a conditioning to the marihuana concentrate which was given subsequently.

The description of these six psychotic episodes fits in with many others found in marihuana literature. They are examples of acute marihuana intoxication in susceptible individuals which comes on shortly after the drug has been taken and persists for several hours.

The main features of the poisoning are the restlessness and mental excitement of a delirious nature with intermittent periods of euphoric and an overhanging state of anxiety and dread.

Three other subjects presented the features of marihuana psychosis.

R.H. Male. White. Age 23. Non-user. In prison for the offense of living on prostitution. The family history was bad. His father never supported his wife or family and there was continual discord at home. When the subject was 9 years old the father deserted the family. Three brothers received court sentences, one for stealing a taxi, one for rape, and one for striking a teacher. R.H. was a problem child at school and on account of truancy and waywardness he was sent to the Flushing Parental School.

He ran away from this school several times and was transferred to the House of Refuge on Randall's Island. At the age of 16 he was discharged. Since that time he had had two jobs, one for three months in a factory, the other for four and one-half months in the W.P.A. When he was 16 he was run over by a truck and was unconscious for a time. After his return to the Riker's Island Penitentiary from Welfare Hospital further questioning concerning his past revealed that he was subject to "fits" occurring once or twice every two months. During the attacks his body became rigid and his mouth felt stiff.

The subject was admitted to Welfare Hospital for the marihuana study on February 20th. After the usual program of examinations he was given 2 cc. of the concentrate on February 27th and February 28th. These doses brought on the symptoms of dizziness and tremor and heaviness of the head and the state called "high" which is characterized by periods of laughter and talkativeness. These effects passed off in a few hours and were followed by drowsiness and a sense of fatigue. On March 1st at 1 p.m. he smoked one marihuana cigarette. Immediately afterwards he became agitated and restless and suddenly lost consciousness. He recovered quickly and stated that he had had visions of angels and had heard choirs singing. Later he had a second short period of unconsciousness. During the afternoon he continued to be agitated and restless and had periods of laughing and weeping. After he was given phenobarbital he went to sleep. On the next day his only complaint was that he felt dizzy. Following this episode he was given 4 cc. Of marihuana concentrate on March 3rd and 2 cc. on March 10th and 2 cc. of tetrahydrocannabinol on March 5th and 4 cc. on March 8th. The effects corresponded to those seen after the earlier administrations of 2 cc. doses of the concentrate.

On March 11th R.H. was given 5 cc. (75 mg.) of the tetrahydrocannabinol at 11 a.m. and 3 cc. at 2 p.m. No unusual effects were noted during the afternoon and he ate his supper with appetite at 4:30 p.m. At 6 p.m. he became restless, apprehensive and somewhat belligerent. He felt that something had happened to his mother, that everybody was acting queerly and picking on him. He continued to be agitated and fearful, refused medication and slept poorly. This condition persisted and on March 13th he was returned to Riker's Island. After four days there he became quiet and composed. The psychotic state cleared up completely. The resident psychiatrist's report was: Impression 1. Psychosis due to drugs. (Marihuana experimentally administered.) Acute delirium, recovered. 2. Convulsive disorder, idiopathic epilepsy. Petit mal on history.

H.W. Female. White. Age 28. Non-user. Drug peddler, serving three years' indefinite sentence for unlawfully possessing a drug. Her parents died when she was about 10 years old and she was raised in an orphanage. At the age of 19 she entered a training school for nurses, but gave this up after four months and supported herself by prostitution. Her sister and her sister's husband were drug addicts and through them she began taking morphine and heroin, being, according to her account, depressed and dissatisfied at the time. She continued using these drugs up to the time of her arrest, a period of eight years. In 1938 she married a man who was also a drug addict, and engaged in the drug traffic.

On May 7th she was given 2 cc. of marihuana. Aside from a headache and a feeling of muscular weakness and uncoordination, the effect was to make the subject feel gay and very good-natured On May 8th she was given 3 cc. Of the concentrate and became somewhat confused and unsteady, irritated and upset at carrying out tests, and greatly worried about the physical symptoms. Five hours after she had taken the drug the effects had largely passed off. Six hours later, however, she became restless and agitated, moving about constantly, and worried about past conduct. This state continued for a few hours. On other occasions the subject was given marihuana in doses of 2, 3, and 4 cc. Twice after the administration of 3 cc. The general effect was of a euphoric type, and after 4 cc. Had been given a state of sadness set in on two occasions and one of euphoria on a third. Toward the end of her stay the subject became depressed and moody, constantly dwelling on the belief that she had committed unpardonable sins.

She was returned to the House of Detention on June 2nd, transferred to the Psychiatric Division of Bellevue Hospital on June 9th, and from there was sent to Matteawan State Hospital on July 10th. On admission to the State Hospital she appeared confused, retarded, apprehensive, and depressed. She had a marked feeling of guilt. She began to improve in September and was discharged, cured, in January. Since her return to New York she reports at frequent intervals to the parole officer. She has secured employment in a food shop and is to be promoted to the position of manager of the shop.

The diagnosis made at the State Hospital was: Psychosis, due to drugs and other exogenous poisons (morphine and heroin).

D.P. Male. Colored. Age 23. Occasional user. Sentenced for unlawful possession of drugs. Since graduation from high school at the age of 16 he had had no occupation. His criminal record dated from his graduation. He was arrested in 1934 for disorderly conduct and in the same year sentenced to Elmira Reformatory for five years for second-degree assault. He was paroled in 1936, but during the same and the following year was arrested three times for assault or robbery. He was returned to Elmira where he remained until his discharge in 1940. In August 1940 he was arrested for the possession of drugs and sentenced to a three-year indefinite term. He had served eight months of this sentence when he was admitted to Welfare Hospital as a subject for the marihuana study.

During his stay at Welfare Hospital, D.P. was given marihuana in the form of a concentrate and as cigarettes on numerous occasions. His symptoms and behavior corresponded to those usually seen, lasting a few hours with no after-effects. When the time came for his return to Riker's Island he urged that he be allowed to stay at the hospital and assist in the study. Two weeks after his return to the penitentiary he developed a psychosis characteristic of schizophrenia. He was transferred to Matteawan where the diagnosis made was: Psychosis with psychopathic personality.

These three cases are of special interest from the standpoint of the relationship of marihuana to the psychosis. The first subject, R.H., had a definite history of epileptic attacks. After smoking one marihuana cigarette he experienced an acute confusional state which lasted a few hours. In the second episode which lasted six days there was a more prolonged confusional state. Epileptics are subject to such attacks, epileptic or epileptic equivalents, which may be brought on by any number of upsetting circumstances. In this case marihuana is the only known factor which precipitated the attack.

The second subject, H.W., was a heroin addict of long standing. During her stay in the hospital, in her retrospective reports on her marihuana experiences there were usually included expressions of worry and remorse at her failure to answer questions or perform tests honestly, informing on the other women in her group, and denials concerning a syphilitic infection she thought she had had. Prior to this incarceration she had had no prison experience. The mental picture developed from the study at the hospital and at Matteawan and the subject's subsequent history represent a fairly typical example of what is termed a prison psychosis.

The third subject, D.P., did not develop his psychosis until two weeks after he had been returned to the Riker's Island Penitentiary. He had shown no unexpected effects from marihuana and had hoped to be allowed to stay on at the hospital instead of going back to prison to complete more than two years of an unexpired sentence. At Matteawan this subject was considered to have an underlying psychopathic personality. His case also may be taken as an example of prison psychosis. With both the second and third subjects, the exact role of marihuana in relation to the psychosis cannot be stated.

Dr. Peter F. Amoroso, Commissioner of Correction of the city of New York, has given us information concerning the prisoners sentenced to the penitentiary at Riker's Island from whom our subjects were drawn. During the year beginning July 1, 1941, and ending June 30, 1942, there were 1,756 inmates in this institution. They had received an indeterminate sentence, that is, from a minimum of a few months to a maximum of three years. Of this group, 175 were subjected to intensive study by the psychiatrist because they were considered possible psychotic cases, 117 were sex offenders, and 200 were miscellaneous cases referred for mental observation, making a total of 492. Twenty-seven of these cases were committed to state institutions for the criminal insane, namely, 25 to Matteawan and 2 to Dannemora.

Commissioner Amoroso, after reviewing these cases, writes as follows:

"The prison atmosphere may place a most severe strain on those who are physically or mentally abnormal upon commitment . . . Emotionally unstable persons find themselves during incarceration denied the assertion and enjoyment of the basic human urges and impulses and it is natural to expect, therefore, that prison life may result in various types of explosions, such as psychoses, neuroses, sex perversion, and even physical and moral deterioration.'

"I am indeed surprised that we had so little trouble with our volunteers upon completion of their study and sojourn at Welfare Hospital, and the few psychotic episodes that occurred are exactly what we would expect in the whole group without considering the administration and effects of excessive doses of marihuana."

Summary

In the study of the actions of marihuana in respect to subjective and objective symptoms and behavior, the marihuana was given a number of times to each of the subjects in the form of the concentrate taken by stomach. The amount given ranged from 2 to 22 cc., in most cases from 2 to 5 cc. After marihuana was taken, the systematic action became evident in from one- half to one hour and the maximum effects were seen in from two to three hours. They passed off gradually, usually in from three to five hours, although in some instances they did not completely disappear until twelve or more hours.

Of the symptoms occurring, a feeling of lightness in the head with some dizziness, a sensation of floating in the air, dryness of the throat, hunger and thirst, unsteadiness and heaviness in the extremities were the most frequent. Tremor and ataxia, dilation of the pupils and sluggishness in responsiveness to light were observed in all subjects.

From observations on the behavior and responses of the subjects, it was found that a mixture of euphoria and apprehension was generally present. If the subjects were undisturbed there was a state of quiet and drowsiness, and unawareness of surroundings, with some difficulty in focusing and sustaining mental concentration. If they were in company, restlessness, talkativeness, laughter and joking were commonly seen. A feeling of apprehension, based on uncertainty regarding the possible effects of the drug and strengthened by any disagreeable sensations present, alternated with the euphoria. If the apprehension developed into a state of real anxiety, a spirit of antagonism was shown. However, any resistance to requests made to the subjects was passive and not physical and there was no aggressiveness or violent behavior observed. Erotic ideas or sensations when present took no active expression.

Six of the subjects developed toxic episodes characteristic of acute marihuana intoxication. The dosage varied from 4 to 8 cc. of the concentrate, and the episodes lasted from three to six hours, in one instance ten hours. The effects were mixtures of euphoric and anxiety states, laughter, elation, excitement, disorientation and mental confusion.

The doses given were toxic to the individuals in question but not to others taking the same or larger ones. Once the drug had been taken the effects were beyond the subject's control. The actions described took unusual expression because for the particular subject at a particular time the dose was unusually effective. A corresponding toxicity did not occur from cigarettes for here the effects came on promptly and on the appearance of any untoward effects, the smoking was stopped.

In three of the subjects a definite psychotic state occurred, in two shortly after marihuana ingestion, in one after a two week interval. Of the first two, one was an epileptic and the other had a history of heroin addiction and a prepsychotic personality. The third was considered a case of prison psychosis. The conclusion seems warranted that given the potential personality make-up and the right time and environment, marihuana may bring on a true psychotic state.

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