Psychoses, Adverse Reactions, and Personality Deterioration

Chapter 10 from Marihuana Reconsidered, pp. 253-290, by Lester Grinspoon, M.D., 1971, 1977, Harvard University Press, ISBN 0-674-54834-5, Library of Congress Catalog Card Number 77-76767, available for $19.95 plus postage from Quick Trading Company, P.O. Box 429477, San Francisco, CA 94142-9477 (510-533-0605).

Introduction 1

1 The History of Marihuana in the United States 10 2 From Plant to Intoxicant 30 3 Chemistry and Pharmacology 42 4 The Acute Intoxication: Literary and Other Reports 55 5 The Acute Intoxication: Its Properties 117 6 Motivation of the User 173 7 Turning On 185 8 The Place of Cannabis in Medicine 218 9 Addiction, Dependence, and the "Stepping Stone" Hypothesis 231 10 Psychoses, Adverse Reactions, and Personality Deterioration 253 11 Crime and Sexual Excess 291 12 The Campaign against Marihuana 323 13 The Question of Legalization 344 14 Marihuana: Six Years of Reconsideration (with James B. Bakalar) 372

Abbreviations 403 Selected Bibliography 407 Notes 417 Index 463

Psychoses, Adverse Reactions, and Personality Deterioration

The literature on the relationship of cannabis to the development of psychosis is both vast and exceedingly confused, and as one reads through its more noteworthy contributions, a definite dichotomy, one based largely on locale and observer, becomes evident. Authors from India, Egypt, Turkey, Africa, and other Eastern lands are largely in agreement that their psychiatric institutions are populated by a large number of cases of insanity which can be directly attributed to hashish. In the late 1800's and early 1900's particularly, but even as late as 1967, papers and official statements appeared which adamantly condemn the drug as harmful both to the mental health of the individual and to the integrity of the social fabric of their countries. It is striking that numerous discussions of the psychotogenic effects of cannabis in Western literature (notably those written recently in the United States) are in quite an opposite vein; they either exonerate marihuana from these charges or else cite only a handful of cases to support the contention that its use leads to the development of psychoses. Clearly, there are some discoverable factors or circumstances which account for the existence of such a wide dichotomy in world medical opinion. A critical look at this literature may reveal some reasonable conclusions that can be drawn with regard to cannabis and psychosis.

Examining first the Eastern literature, one is immediately impressed with the magnitude of the role that cannabis apparently plays in admissions to psychiatric facilities. Authors from the East would have us believe that anywhere from one-fourth to nine-tenths of the admissions to their institutions result from the use


of this drug. There are seemingly endless numbers of reports written by staff members and superintendents of Egyptian and Indian insane asylums that are frequently cited as evidence of the psychotogenic effects of cannabis. An article by J. H. Tull-Walsh serves the useful purpose of summarizing 21 of these reports written from the l860's through the 1870's; many of them cite huge percentages of the patient population of their institutions as cases of "cannabis insanity."
1 For example, J. Wise, the Superintendent of the Dacca Asylum, writing in 1873, stated that "between thirty and fifty percent of the admissions in the Indian asylums was due exclusively to the effects of hemp drugs." 2 A. Eden, the Secretary to the Government in Bengal, estimated that "four-fifths of all the cases where the cause is known" are due to gánja. 3 The "Annual Report Dacca Lunatic Asylum for 1863" estimates that "165, or 50 per cent of the total number treated, have been distinctly traced to that cause [ganja]"; in writing the "Annual Report" for this same institution in 1869, H. C. Cutcliffe states, "Of 312 patients, no less than 123 are alleged to have become insane from ganja smoking and drinking." 4 Similarly, G. F. W. Ewens, in 1904, reported that 161 of the 543 cases of mania in male admissions to the Punjab asylum during the period 1900 to 1903 were attributable to excessive indulgence in hemp drugs. 5 R. F. Hutchinson, writing in 1865, reports that 90.6 percent of all cases in asylums in Bengal were due to indulgence in ganja, bhang, opium, or spirit, and that if these "causes were checked or removed the asylums would speedily be depopulated." 6 However, one discovers in reading these and similar reports that the authors based their findings of "hemp insanity" largely on inadequate or circumstantial evidence riddled with discrepancies.

To begin with, a number of authors mention that a diagnosis of "hemp insanity" is often taken directly from police reports which are required to state a reason for psychiatric hospitalization. 7 Cannabis is the easiest and least complicated reason for the police to use. Apparently it is common knowledge, even to the asylum superintendents, that this is the usual practice; yet no effort is made to correct this matter on the records subsequent to the patient's admission. In addition, as A. J. Payne notes, repeated readmissions are included in these figures, even when they are not cases of recurrent insanity but only repeated intoxication; in other words, the diagnosis of "hemp insanity" once made, per-


sists. 8 Another group of readmissions wrongly included in these figures are those patients "removed by relatives and brought back from difficulty or expense in managing them at home." 9 In addition, many of the reports citing these high figures were generated by institutions admittedly so overcrowded and understaffed that accurate record-keeping was impossible. J. Wise, Superintendent of the Dacca Asylum, writes: "An attempt has been made this year to distinguish between those cases of insanity clearly due to gánja smoking and those in which the use of gánja has only been occasional, and, therefore, insufficient to excite insanity. The attempt has not been successful. For want of any other reason, it has been necessary to enter under the heading gánja several who were merely reported to have indulged in its use." 10

These are just a few of the ways in which the figures for so-called "cannabis insanity" have swelled to a point totally out of keeping with the facts, There are other less obvious but equally important contributing factors which will be discussed in greater detail, but even at this point one can unequivocably state that Eastern reports are exaggerated and inaccurate. Tull-Walsh himself estimates that "want of accuracy in ascertaining a cause renders about 50 per cent. of the cases of insanity, said to be due to gánja, etc., doubtful." 11 Sandwiched among these reports one can find another note of reason by A. MacKenzie who, in writing a government resolution in 1871, stated that

the number of cases attributed to gánja is 169 out of 230 admissions is which a cause was known, but it may be that it has become a habit to attribute insanity to gánja. The Lieutenant-Governor would be glad to have it specially noted in the reports if there are generally good grounds for setting down this drug as the cause in so many cases. 12
An Egyptian report which is frequently quoted as incriminating cannabis as a cause of insanity was written by J. Warnoch, Medical Director of the Egyptian Hospital for the Insane in Cairo at the turn of the century, and the first to institute some record-keeping procedures in what was then the only, and accordingly very crowded, psychiatric facility in Egypt. Some difficulties common to most Eastern reports are especially evident in this one. In investigating the hypothesis that hashish is instrumental in causing a large proportion of the insanity in Egypt, Warnoch developed


five categories of "hashish insanity." Aside from those cases of temporary intoxication (type 1) or pleasant, dreamlike states, which do not require hospitalization, he reported observing numerous instances of the following hashish-induced conditions:
2. Delirium from hasheesh, which is accompanied by hallucinations of sight, hearing, taste, and smell, often of an unpleasant kind. Delusions of persecution often occur. The idea that the subject is possessed by a devil or spirit is common. Great exaltation and the belief that the individual is a sultan or prophet may occur. Suicidal intentions are rare. . . . Hasheesh delirium is a less grave state both physically and mentally [than delirium tremens]. Some cases are stuporous in type.

3. Mania from hasheesh. - This varies in degree of acuteness from a mild short attack of excitement to a prolonged attack of furious mania ending in exhaustion or even death. Most cases are exalted, and have delusions of grandeur or of religious importance; persecutory delusions occur frequently, and provoke violence towards others, but not suicide. Restlessness, incoherent talking, destructiveness, indecency, and loss of moral feelings and affections, are all ordinary symptoms. A certain impudent dare-devil demeanour is a characteristic symptom. Hallucinations are not so marked as in alcoholic mania, but those of hearing and taste are not uncommon; delusions of being poisoned are often based on the latter variety. A few cases are more melancholic than maniacal in demeanour, and exhibit extreme depression and terror with hallucinations of hearing (threatening voices, etc.).

4, Chronic mania from hasheesh, including a form of mania or persecution. Many of these cases are not distinguishable from ordinary chronic mania.

5. Chronic dementia from hasheesh describes the final stage of the preceding forms. 13

Warnoch is by no means the only author who developed a symptomatology for "hashish insanity." Ewens did so in great detail, as did J. E. Dhunjibhoy, who wrote: "In India, hemp drugs, whether taken in excess or moderation, over a prolonged period, produce a special form of mental disorder, which is characterized by a definite train of symptoms which is fairly uniform in character." He enumerated as typical of a "hemp insanity" case: "intense


excitement, grandiose ideas, tendency to willful violence and destruction, the peculiar eye condition, . . . total amnesia of all events, . . . with a history of a drug habit." 14

What is obvious about the syndromes established by Warnoch and the typical symptoms listed by Dhunjibhoy (excluding the eye condition and drug habit) is that they cannot be ascribed exclusively to the effects of hashish. They describe both schizophrenia and, to a lesser extent, manic-depressive psychoses (particularly manic phase), and it is not unlikely that many if not most of the vast number of schizophrenics and manic patients admitted to psychiatric facilities in the East, especially in the past, have been sheltered under the diagnostic umbrella of "hemp insanity." In fact this possibility has been noted by another Eastern author, F. Kerim, who has studied the problem of hashish in Turkey; his observations of patient populations similar to those studied by Warnoch led him to take a broader perspective, one probably more consistent with the reality. He writes, "The symptoms [of "hashish insanity"] are not unlike those in cases of schizophrenia, with bizarre hallucinations and delusions, impulsive and compulsive phenomena, paranoid formations, fear reactions, etc. Differentiation between them and transitory schizophrenic episodes is difficult." 15

Since Warnoch acknowledges that there is no pathognomonic symptom of "hasheesh mania," how then did he differentiate cases of "hasheesh insanity" from schizophrenia and other forms of mental disease? The following is his account:

The discovery of hasheesh in the patient's clothing, or concealed in his ears or mouth, occasionally betrays the nature of the case. On admission every male patient is questioned with regard to hasheesh, and a report made on the amount he takes and his attitude towards the charge; excited protests and denials of the habit are known by experience to indicate a hardened hasheesh smoker. As the mental state of the patient improves, he is again questioned about hasheesh, and before discharge he is invited to give full details of his habit. By comparing the repeated statements and by noting his knowledge or ignorance of the various details of hasheesh smoking, such as the price of the gozeh, the different qualities of the drug, etc., it is not difficult in most cases to form an opinion as to whether the case is one of hash-


eesh. The evidence of relatives is occasionally of use, but it is less reliable than the repeated cross-examination of the patient; numbers of the Cairo cases are known to be frequenters of hasheesh cafés from being seen there by hospital employés. 16
From the above it is clear that at least in Warnoch's report the diagnosis of "hemp insanity" was based not on the existence of certain clear-cut signs and symptoms, but solely on more or less substantiated reports that the patient had been a hashish user at the time of his hospitalization. Thus, of two patients exhibiting the same symptoms of mental disturbance, one, whose wife acknowledged him to be a user, could have been included in Warnoch's figures as a case of "hemp insanity," while the other, whose relatives were not as willing to speak, would have been placed in some other diagnostic category - most probably schizophrenia. Figures compiled in such a fashion, if they are of any use at all, provide more of a sense of the number of psychotics who use hashish rather than the number of hashish users who become psychotic.

A more modern study than Warnoch's, and, like his, one which is frequently referred to by those who assert that hemp produces psychosis, is that of A. Benabud. 17 His study, like Dhunjibhoy's, is largely dependent on the contention that there is a specific syndrome entity, the "cannabis psychosis." 18 He asserts that a significant proportion of the patient population at the Berrechid Hospital in Morocco suffers from this type of psychosis. He notes that in 1955 the number of generic "cannabis psychotics" was 239 out of 1,017 hospitalized male Moslem patients, 72 percent of whom admitted to some experience with kif. In 1956, the figure fell to 68 percent; the number of "cannabis psychoses" was 328 out of 1,252 male Moslem admissions. However, the clinical data which Benabud presents are unclear. First, it is not possible to define those particular clusters of symptoms and signs which distinguish a "cannabis psychosis" from other acute toxic states, and, particularly in Morocco, from states associated with malnutrition and endemic infection. Secondly, Benabud asserts that the number of kif smokers "suffering from recurrent mental derangement" is not more than 5 per 1,000. Now this is on the low side of the estimates of active prevalence rates for total psychoses from different parts of the world. Therefore, we would have to assume


either (1) that there is a much lower prevalence of psychoses other than "cannabis psychoses" among kif smokers in Morocco, or (2) that there is no such thing as a "cannabis psychosis," and that the drug is contributing little or nothing to the prevalence rate for psychoses. Two highly respected Indian authors, I. C. and R. N. Chopra, completed a study of 466 cannabis smokers in which they found 9 cases of insanity; in a second study of 772 cannabis drinkers they found 4 such cases. The data from these two samples yielded active prevalence rates of 1.93 percent and 0.52 percent, respectively. 19 These rates do not differ significantly from the active prevalence rates for total psychoses found in surveys in both Europe and North America, rates which range from 0.6 percent to 2.1 percent of adult populations. 20 This further supports the contention that the use of cannabis does not contribute significantly to the prevalence of psychoses.

It is possible that the widespread use of a drug which, with excessive dosage, may cause toxic psychoses, could, providing those toxic psychoses are short-lived, lead to an increased incidence of psychoses without significantly elevating the prevalence rates for psychoses. In considering hospital-admission figures from the East, we are in fact dealing to a large extent with individuals who consume large quantities and potent forms of cannabis. As Ewens writes, "I have repeatedly met with instances in which after recovery a man has attributed his insanity to a single large dose of bhang or charas generally stated to have been administered by a faqir. . . . The history always given is that they have been induced to partake of a large amount, that they fell into a state of nasha (intoxication) and remember nothing more until finding themselves in custody or in the asylum." 21 Even Warnoch states: "Probably only excessive users, or persons peculiarly susceptible to its toxic effects, become so insane as to need asylum treatment. Whether the moderate use of hasheesh has ill effects I have no means of judging." 22 Tull-Walsh writes that there are "a number of cases in which the abuse of Indian hemp drugs, either alone or combined with datura or alcohol, has produced a violent and prolonged intoxication followed by a maniacal, melancholic, or demented condition. In these cases recovery takes place in a very short time; indeed, in many of them the individuals are sane, or almost sane, when they reach the asylum." 23 I believe that the episodes for which Tull-Walsh's cases were hospitalized may be


considered short-lived toxic psychoses and that they do not differ substantially from some of the episodes of Gautier, Ludlow, and Taylor which were described in Chapter 4. Large amounts of cannabis - particularly, if not almost exclusively, ingested hashish - can lead to such a degree of intoxication that the extreme perceptual distortion, anxiety to the point of panic, and temporary loss of capacity to test reality produce a clinical picture which is often indistinguishable from other toxic psychoses. These, however, are self-limiting episodes and quite different from functional psychoses such as schizophrenia or what is meant by those who believe in the "cannabis psychosis."

W. Grossman touches on this subject in reporting on "emotional disorders" of six Westerners who used native hashish while visiting in India. "One shouldn't confuse American marijuana with what is commonly available in India: They are different! Indian hashish or 'marijuana' has a high that can last up to 3 days, the high consisting of severe anxiety and confusion," 24 according to one such user. As was illustrated in Chapter 4 by the reactions of, for example, Bayard Taylor as compared to Mr. X, this American discovered there is quite a difference between the ordinary use of marihuana (bhang) and large doses of ganja or charas. It is possible, writes Grossman, that "the observed frequencies of serious adverse reactions to cannabis products in different areas may merely represent different segments of a dose-response curve to THC." 25 All but a very few of the Eastern reports refer exclusively to ganja or charas in citing mental-hospital admission statistics; it seems clear that to the extent that cannabis plays a significant role in hospital admissions it is a drug which, when used excessively in its most potent forms, may lead to the development of a short-lived toxic psychosis.

To an undiscoverable extent one is also dealing with ganja which has been adulterated with other substances such as opium or datura, and these substances may modify or enhance the effects of the intoxication. Tull-Walsh says that this is a common practice, but it is impossible, at this time, to determine how great an influence it might be in the number of cases of toxic psychosis. 26

Another point, made by Warnoch and by A. Boroffka, is the existence in any population of some individuals who are "particularly susceptible to its [hashish's] toxic effects." 27 Such persons are already suffering from some form of mental instability, and in


this view the drug serves as an exciting agent; the excited or irrational behavior may be considered more a manifestation of that predisposition than a direct effect of the drug. As Tull-Walsh puts it:
It is not very improbable that, owing to the fact that these persons are of a neuropathic diathesis, and in them a tendency to insanity exists, and has always been latent, hemp drugs in excess, or even in quantities which would not damage a man of robust nervous constitution, have acted as an exciting cause, making manifest a mental weakness which might not have shown itself in the absence of such indulgence. 28
A last but equally important factor that undoubtedly contributes to the numbers of those reported to be suffering adverse effects from cannabis use is the environment. In underdeveloped countries such as Egypt or India there is a lack of sufficient food for good nutrition for large portions of the populace; juxtaposed with this fact is the observation that "the violent intoxicating effects [of ganja or charas] are less marked, or not seen at all, in persons having a regular and wholesome supply of food." 29 This is supported by observations of the Ramawats "who are the greatest smokers in Eastern Bengal, [and] seldom, if ever become mad. They, as well as other natives who exceed in smoking gánja, invariably live very well, and they maintain that as long as plenty of food is taken its effects are innocuous. . . . During the last six years none of these luxurious mendicants have been admitted into the asylum, although they are very numerous in the city of Dacca." 30

In addition to being deprived of sufficient food and thus being more susceptible to the adverse effects of any drug, the poorer people in these countries also exist in extremely overcrowded living conditions which, from a public health standpoint, are deplorable at best. A sense of general despair and hopelessness prevails which nourishes mental illness, and individuals living in such environments may be seen as among those particularly susceptible to both the use and the adverse effects of cannabis.

In summary, the Eastern cannabis literature must be read with caution. The large numbers of cases diagnosed as "cannabis psychosis" are often a result of the "fact that no distinction is made between drug induced symptoms and independent schizophrenia,"


and they are greatly increased through both the purposeful and the inadvertent inclusion of cases for which no proper diagnosis has been made. 31 Furthermore, there are vast cultural and economic differences between East and West, and essential differences in the forms in which the drug is used. With all this in mind one can then acknowledge that some unknown (probably small) percentage of the cases cited by these authors as "cannabis insanity" are, in fact, related to use of the drug, in that large doses may lead to the development of a toxic psychosis of short duration, and, in already emotionally unstable and susceptible people, it may excite psychotic-like symptoms.

What of the reports linking cannabis to psychosis in the North American literature? The number of reports contending that such a relationship exists has diminished considerably since the 1920's and 1930's; as H. S. Becker points out, such reports after the 1940's are relatively rare despite the very large increase in the use of the drug. 32 In their study of 310 soldiers who had used marihuana for an average duration of 7.1 years, H. L. Freedman and M. J. Rockmore found no history of psychoses. 33 Of the 60 marihuana users studied by S. Charen and L. Perelman, 77 percent began to use marihuana before the age of 18; the average length of time for smoking marihuana was approximately 6 years, during which some smoked from one to two marihuana cigarettes a day, others as many as ten, but most from four to six daily. None of the patients had a history of psychosis. 34 In the more than 150 marihuana- using patients observed by H. S. Gaskill, there was only 1 who was questionably psychotic. 35 The 34 cannabis-using soldiers who volunteered to be studied by J. F. Siler et al. had used the drug for from 2 months to 4 years, the average period being 1 year and 2 months. They smoked between one and twenty cigarettes daily; the average was five. None was found to exhibit psychotic symptoms. 36 In the La Guardia study there was a high incidence (9 out of 77) of history of psychoses; but this is to be expected inasmuch as these patients were located through hospitals and institutions. 37 In fact, S. Allentuck and K. M. Bowman, during the course of their study of these subjects, became convinced that "marihuana will not produce a psychosis de novo in a well-integrated, stable person." 38

In the North American literature the most frequently cited study in support of the psychotogenic effect of cannabis is prob-


ably the one published by W. Brombag in 1939. 39 But, as H. B. M. Murphy has pointed out, of the 31 patients whose psychoses were reported in this paper to be related to the use of cannabis, 7 were functional psychoses precipitated by the drug, 7 patients were presented as acute toxic psychoses but were readmitted to a mental hospital within two years with the diagnosis of schizophrenia, and another patient, with a similar picture, was readmitted with a manic-depressive psychosis. 40 Further scrutiny of the case material in Bromberg's paper leads me to the impression that an additional number of these patients may have had unrecognized early acute schizophrenic reactions of the type that reconstitute quite rapidly (the so-called "five day schizophrenia"). In the same paper Bromberg reports on 67 prisoners who were users of marihuana; there were among them neurotics and personality disorders, but none were found to be psychotic.

More recently there have appeared a number of case reports which are meant to illustrate, sometimes quite alarmingly, the psychotogenic effects of marihuana. For example, D. Perna recently published a very brief paper in which she presented a case which she asserted demonstrated "that marihuana may have a psychotogenic effect even in an individual with a healthy premorbid personality." 41 However, the information she presented about this patient leads one to question seriously how healthy he was; he had suffered from nocturnal enuresis until he was 18 years of age, and at age 16 suffered from depression serious enough to require six months of psychotherapy, and he was depressed again at the time he used marihuana. Her statement that this schizophrenic reaction developed in a healthy premorbid personality stretches the concept of premorbid health.

The opening sentences in a much more detailed report tided "Marihuana Psychosis: A Case Study" suggest that the author, G. D. Klee, is determined to avoid such a mistake. He states: "I have seen numerous patients, however, who have had a wide variety of psychiatric difficulties associated with marihuana use. Most of these patients, however, have had pre-existing psychiatric disturbances and have also taken other drugs, so that it is difficult to establish a definite cause-effect relationship between marihuana use and the ensuing psychiatric disturbance." 42 After this preface he asserts: "The case to be presented is unique in that the relationship between marihuana use and the psychiatric disturbance is un-


mistakable." 43 The author records in considerable detail the accounts of a 26-year-old man and his girlfriend in which they relate the horrors of his psychotic experience, which occurred after they had smoked two marihuana cigarettes between them (they had on four or five previous occasions used cannabis without any adverse effects). In summary, the episode was punctuated by "unbelievably horrible" visions of death and hell, during which he became so irrational and violent that his girlfriend called in neighbors who helped her to tic him up. However, the impression that the author is discussing a stable young man with no preexisting psychiatric difficulties who is suddenly crazed by marihuana is completely dispelled by consideration of the facts disclosed in the past and family-history sections of the report. The young man came from a home "filled with tension" where violent behavior between father and sons often erupted; in fact, just two days prior to taking marihuana there had been a "violent episode at home." His girlfriend related how insecure, unpredictable, and impulsive he had been, and she equated the marihuana episode to his behavior when drinking. "Although usually jolly at such times [when intoxicated with alcohol], he can become very irritable and nasty. It has been only when he was drinking that they have had fights. He apparently is quite angry about her refusal to agree to marriage and expresses this anger when drunk. At times, and especially during the marihuana reaction, she has felt that, 'There is something about me that . . . [he] hates very much.' What it might be, she cannot say. She also reported that during the psychotic episode and while tied up in the blanket, . . . [he] was talking about his friend Danny, and moving in such a way as to suggest that they were having enjoyable homosexual relations. This she has not told him, because she believes he feels quite insecure about his masculinity. He also imagined himself having sexual relations with her, and said, 'It's wrong, it's wrong.' " 44 She reported that, on the only occasion that they had sexual intercourse, "he expressed feelings of guilt and inadequacy about his sexual performance." 45 In discussing his past history, the young man denied "any history of previous psychiatric symptomatology of any nature. . . . He does report, however, that on a few occasions he has had unusual and alarming reactions to alcohol. Although not a habitual or usually a heavy drinker, he has used liquor many times. On a few occasions, usually when high (on about a half pint of whiskey), he has been ex-


plosive and assaultive. On very slight provocation he has fought and beaten one, two, three, or four other men - friends or enemies - sometimes much larger than himself. On these occasions he has been quite vicious, continuing to beat and kick his victim after knocking him down. His memory after the event tends to be rather hazy. These occurrences are described more with an air of alarm than of braggadocio. Only on rare occasions, in adult years, has he ever been violent when not under the influence of alcohol. He came in search of psychiatric help after the realization that there was something dangerously explosive inside of him that was brought out by alcohol and marihuana." 46 The author directly acknowledges at the close of the paper this man's "latent psychopathology" and further reports the patient admits: "On occasion, drugs, or as he puts it fearfully, 'almost anything else' which interferes with ego functions, might bring out the latent psychopathology. . . . In other words, the marihuana augmented his psychopathology and vice-versa." 47

Thus, the author presents a young man who has a poor self-image, intense guilt feelings, an impulse disorder with a propensity for violence, and who by his own acknowledgment is so shaky that "almost anything" could have precipitated a temporary psychotic state. This paper ("Marihuana Psychosis: A Case Study"), the title of which commends it to those who wish to emphasize the alleged dangers and horrors of cannabis, might just as easily have been written about the dangers of alcohol for such a susceptible person; but a paper about so common an occurrence would undoubtedly not have been accepted for publication.

Another common flaw in reports linking marihuana and psychosis is the apparent willingness on the part of those whose bias is antimarihuana to gloss over the fact that the persons involved are often multiple-drug users. P. Dally has written of four cases of mental disorder which in his opinion incriminate marihuana as a causative factor. 48 An examination of these case summaries leads to considerable doubt regarding this opinion, and in turn reveals some of the discrepancies and weaknesses which are often observed in reports addressed to the psychic dangers of cannabis. Two of these case reports are as follows:

An art student of 19 experimented with lysergic acid diethylamide (L.S.D.) over a period of several months without obvious


ill effect. At a party he took 100 mg. [sic] L.S.D. by mouth and smoked two "reefers." He felt "depersonalized, about to disintegrate, and go mad." He became extremely anxious. He was treated with trifluoperazine 2 mg. three times a day and chlordiazepoxide 10 mg. three times a day for a fortnight, and symptoms subsided. A week later he again smoked a "reefer." Anxiety immediately returned and he experienced fleeting visual hallucinations. 49
The initial symptoms were much more likely to have been caused by the LSD than the cannabis. It is probable, however (as will be discussed later), that the symptoms he presented "a week later," the flashbacks of his experiences with LSD, were precipitated by the use of marihuana. The author remarks, "After full recovery he was resolved not to smoke marijuana again." 50 It is regrettable that his resolve did not include LSD; if the aim of this paper was anything but making a case against marihuana, the author would have noted this.
This [next] case concerned a man who "under the influence of marijuana" tried to drill a hole through his skull. He was "under the influence of a group of people who believe that, after a suitable period of preparation with L.S.D. and marijuana, trepanning of the skull, by releasing cerebral pressure, will enable an individual to conquer time." 51
The author summarizes: "Although he showed no overt psychotic signs, other than what amounted to a delusional belief in this idea, his history suggested schizophrenia simplex." 52 Why is this case cited as one illustrating the undesirable effects of marihuana? If one is considering causes for the irrational act of trepanning the skull, then indictments should first be made against this individual's "history of suggested schizophrenia simplex," next his involvement with a group of people suffering a shared delusion, and then quite possibly the use of LSD. The only reasonable statement to be made here about marihuana is that it could have been one of several possible contributing factors. Thus, to title this piece "The Undesirable Effects of Marihuana" and then attribute to this drug the probable effects of LSD and preexisting psychic disturbance is misleading and contributes to the long list of misconceptions about marihuana.


Another recent addition to the American literature on the subject of marihuana and psychoses further obfuscates the matter. The causal relationship between the smoking of marihuana and what J. A. Talbott and J. W. Teague describe as "toxic psychoses" is quite shaky and based on only three detailed cases described as representative. In one case they attempt to establish marihuana as the precipitant of a reaction with the statement: "He had smoked a pipeful of 'strange tasting tobacco' two days previously and had felt light-headed and 'funny.' " 53 Furthermore, many if not most psychiatrists would have diagnosed these cases as acute panic states, not toxic psychoses. By their own acknowledgment, up to 65 percent of soldiers in Vietnam have used cannabis at least once during their tour of duty; they further assert that approximately 50 percent of the cannabis preparations seized in Vietnam are laced with opiates. Yet these authors insist that the reactions they have described are due to cannabis. One would expect in any war zone that there would be a number of short-lived acute psychotic states; the key question, to which these authors do not address themselves, is whether there is a higher incidence of these states among soldiers using marihuana than among those abstaining. While these authors acknowledge that the incidence of combat reactions in Vietnam is low in comparison with other wars, a possibility which apparently never occurred to them is that widespread use of cannabis may indeed to some extent be protecting that population from psychoses. 54

The psychiatric incidence rate for U.S. Army troops in Vietnam was reported to be 12 per 1,000 strength per year during the calendar years 1965 and 1966. This rate is much lower than that recorded for both the Korean War (73 per 1,000 strength per year July 1950 to December 1952) and World War II (between 28 and 101 per 1,000 strength per year September 1944 through May 1945). During World War II, 23 percent of all cases evacuated for medical reasons were psychiatric cases; the percentage for the comparable group in Vietnam has been approximately 6 percent. 55 Many factors have undoubtedly played a part in this decreased incidence, including changes in rotation policy, improvements in training, early treatment at forward areas, etc. (One would imagine that a difference tending toward an increased psychiatric incidence rate among the soldiers in Vietnam, as compared with World War II and the Korean War, is the fact that many soldiers experience


conflict over the Vietnam War's morality and legality and the part they are compelled to play in a foreign policy which often seems genocidal.) It is certainly possible that these differences between the Vietnam War and the two preceding ones account for the dramatic decrease in psychiatric illness, but it is also at least conceivable that another major difference, the much more widespread and frequent use of cannabis, may also be playing an important role. One soldier in Vietnam, writing to his mother in May 1970, puts it this way:
Is it any wonder people take advantage of the pot over here? It really helps. It's helped me more to get my mind right than the stuff I'm supposed to be taking. The only medication I do use from the Witch Doctor is the sleeping pills. I have a hard time going to sleep at night.

Like I said before, I don't want you or anyone else to be worried over me. I can assure you that my mind is really above this mess and I'll make it through. I found out you can't ask yourself "Why?" or you'll go crazy trying to find an answer. Sure, you can argue all night at some party in the comfort of the World but not here where it happens. There is no answer to Why? on the ground after a firefight. Just bodies. So don't look at your dead friend and ask Why. I think that's what was messing me up. 56

It is a curious fact that while a great deal of attention has been devoted to the hypothesis that cannabis has a causal relationship to psychosis, very little has been written about the possibility that it might protect some people from psychosis. An outstanding feature of many of the surveys cited above is that while few or none of the users were found to be psychotic, many of them did suffer from neuroses or personality disorders. I think that it is safe to say that any population of marihuana users will embrace more mental disturbances of varying types and degrees than a comparable one of nonusers. Thus, one would expect that the prevalence of psychoses among cannabis users would be greater than that of the general population. This does not appear to be so and suggests the possibility, which also occurred to H. B. M. Murphy, that the use of this drug may indeed be protecting some individuals from psychoses. 57 Here one might suppose that the


drug serves to provide relief from, or at any rate dull, the impact of unbearable anxiety or an overwhelming reality.

Fortunately, recent literature also contains a number of studies and reports which do not appear to harbor either a pro- or an antimarihuana bias and appear to be scientifically sound. One such study, published in 1968, is that of L. J. Hekimian and S. Gershon. They conducted a survey of 112 randomly selected, hospitalized drug abusers. Two senior psychiatrists took careful and thorough patient histories within 24 hours of admission. They included demographic and social data, psychiatric anamnesis, and paid particular attention to the history of illnesses that occurred before these patients were hospitalized. In each case a drug was presumed to have played a part in the development of the illness for which they were hospitalized. Eight of the patients had been admitted to the hospital because of psychiatric difficulties that appeared after they had used marihuana. What of their history? Six of the eight had previously taken LSD; seven had had previous psychiatric treatment or hospitalization. Six manifested primary and secondary symptoms of schizophrenia prior to smoking marihuana; one was a schizoid and one was a depressive personality prior to smoking marihuana. The authors write, "The schizophrenics were paranoid or undifferentiated on admission, but several days later, when there no longer were drug effects, their illnesses were well documented." 58 If it were not for these careful history-taking procedures and the candor of the authors, these eight cases could easily have been presented as clear and uncomplicated examples of marihuana-induced psychosis.

W. Keup recently completed a survey of those psychiatric patients admitted to the Brooklyn State Hospital who had a history of drug abuse. Of the 126 who were thoroughly studied, 14 "were found to have suffered, at some time from cannabis induced psychotic behavior of a more serious nature." 59 Careful psychiatric interviewing and testing revealed that "only 6 of the 14 patients had cannabis-related symptoms at the time of admission, in the remaining 8 patients the symptoms occurred in the past. . . . Only in 2 patients cannabis abuse seemed the direct cause of admission, in 4 other patients it contributed to the events leading to hospitalization." Thus "only in 0.9 per thousand of all [psychiatric] admissions was cannabis found to be the direct cause of hos-


pitalization." 60 Of the two cases where cannabis was labeled as the direct cause, one was diagnosed as a toxic psychosis, and the other as a panic reaction.

Such figures are indeed in striking contrast to those cited by Eastern authors which often run as high as 750 per 1,000. If there is any factual basis for the contention that marihuana, as it is used in the United States, causes psychosis, then one would expect the tremendous increase in its use would directly occasion a substantial increase in the number of cases diagnosed and admitted to hospitals and written about in scientific journals and the press. That this hasn't happened is substantiated by some observations of D. E. Smith. Unlike a clinician who occasionally sees one or two drug cases, he is Medical Director of the Haight-Ashbury Medical Clinic and Consultant on Drug Abuse at the San Francisco General Hospital; in this capacity he has had extensive experience with large numbers of marihuana users, and he has conducted research into the drug practices of a marihuana-using subculture. He writes: "At San Francisco General Hospital 5000 acute drug intoxications were treated in 1967. Despite the high incidence of marijuana use in San Francisco, no 'marijuana psychoses' were seen. In fifteen months of operation the Haight-Ashbury Clinic has seen approximately 30,000 patient-visits for a variety of medical and psychiatric problems. Our research indicated that at least 95% of the patients had used marijuana one or more times, and yet no case of primary marijuana psychosis was seen. There is no question that such an acute effect is theoretically possible, but its occurrence is very rare." 61

Isbell et al., in a controlled study of over 30 subjects (all former opium addicts), found that the dose level of [delta]¹-THC which would lead to a positive mood change, "with patients frequently reporting that they felt happy, gay, silly, and relaxed," was 25 mcg/kg smoking or 75 mcg/kg orally. 62 When they reached dose levels of 200 mcg/kg smoking or 360 mcg/kg orally, "the majority of the patients had 'psychotomimetic effects,' including marked changes in body image, illusions, delusions, and hallucinations." 63 (The authors do not raise the point whether it is accurate to call these subjective alterations "true" hallucinations - see Chap. 5.) They state that while most of the subjects did maintain "insight and ascribed these . . . effects to the drug," two subjects lost insight, did not realize that the effects they were experiencing were drug-


induced, and "even after they had recovered, had difficulty in accepting the fact that their psychotic experiences were due to a drug and more particularly that they were due to a drug isolated from marihuana." 64 There are two problems with this report insofar as it has been used to support the claim that marihuana induces psychoses. First, the smoked dose of marihuana required to produce the "psychotic experiences" in two subjects was eight times the dose required for the usual high. There are a number of drugs which are not ordinarily thought of as psychotogenic, but which, if given at a dose level eight times the ordinary dose, will almost inevitably precipitate a toxic psychosis. Second, it is unjustifiable to draw the conclusion that marihuana will lead to psychoses in normal people when the subject population in this study was composed of former opium addicts who also revealed, according to the authors, "evidence of character disorder." 65

That adverse reactions to marihuana are not seen more frequently is a point which H. S. Becker deals with at length. There has developed in this country a marihuana-using subculture whose members share a knowledge of techniques, a definition of effects, an awareness of the drug's typical course, and the ability to deal with anxiety attacks and other adverse reactions:

When someone experiences disturbing effects, other users typically assure him that the change in his subjective experience is neither rare nor dangerous. . . . They redefine the experience he is having as desirable rather than frightening . . . What they tell him carries conviction, because he can see that it is not some idiosyncratic belief but is instead culturally shared. . . . In all these ways, experienced users prevent the episode from having lasting effects and reassure the novice that whatever he feels will come to a timely and harmless end. 66
Furthermore, the supportive ministrations of this subculture could not possibly have any effectiveness if the drug did produce, quite apart from the user's interpretation, any permanent damage to the mind. Though in some instances transitory adverse reactions do occur, the reassurance of companions and the passage of a day or so will convince the user that the effects he has experienced are not permanent.

It is difficult to understand how, in the face of all the evidence to the contrary, prominent medical men, newspaper reporters,


lawmakers, law enforcers, judges, and others are still publicly stating that the use of marihuana commonly leads to the development of psychoses (see Chap. 12). One problem may be that they latch onto a few of the early Eastern reports telling of asylums overflowing with raving "cannabis psychotics" and without any further knowledge or investigation transpose this horrifying picture to the growing use of marihuana in this country. One such author, an attorney writing in 1966, summarizes his case against marihuana by stating:
A marijuana addict is more easily cured in the early stages than is a morphine, heroin, or cocaine addict. However, as a general rule, more of this drug is used by the addict, and there is a great danger that his brain will sooner or later suffer a complete breakdown and that be will have to spend the rest of his life in an insane asylum. Its use often eventuates in mania and dementia. In the complete distortion and demoralization of the brain, due to the rapidity of its inroads, marijuana is even more harmful than morphine. 67
Such a statement presents, at the very least, a distorted, semi-hysterical view of the consequences of marihuana use, but undoubtedly, and regrettably, many of the readers of The Medico-Legal Journal, in which it was published, did not recognize it as such, and have and will continue to base their medical and legal judgments on such blatantly false and misleading grounds.

While there is little evidence for the existence of a "cannabis psychosis," it seems clear that the drug may precipitate in susceptible people one of several types of mental dysfunction. The most serious and disturbing of these is the toxic psychosis already mentioned. This is an acute state that resembles the delirium of a high fever and is caused by the presence in the brain of toxic substances which interfere with a variety of cerebral functions. Generally speaking. as the toxins disappear, so do the symptoms of toxic psychosis. This type of reaction may be caused by any number of substances taken either as intended or inadvertent overdoses. The syndrome often includes clouding of consciousness, restlessness, confusion, bewilderment, disorientation, dreamlike thinking, apprehension, fear, illusions, and hallucinations. The latter part of the earlier described experience of Bayard Taylor is that of a toxic psychosis induced by a very large dose of


hashish: it is also possible that Fitz Hugh Ludlow experienced this syndrome. In any event, cannabis can induce a toxic psychosis, but it generally requires a rather large ingested dose. Such a reaction is apparently much less likely to occur when cannabis is smoked, perhaps because not enough of the active substances can be absorbed sufficiently rapidly, or possibly because in the process of smoking those cannabinol derivatives which are most likely to precipitate this syndrome are modified in some way, as yet unknown.

There are people who may suffer what are usually short-lived, acute anxiety states sometimes with and sometimes without accompanying paranoid thoughts. The anxiety may reach such proportion as properly to be called panic. Such panic reactions, while they are not very common, probably constitute the most frequent adverse reaction to the moderate use of smoked marihuana. During this reaction the sufferer may believe that the various distortions of his perception of his body mean that he is dying or that he is undergoing some great physical catastrophe, and similarly he may interpret the psychological distortions induced by the drug as an indication that he is losing his sanity. Panic states may, albeit rarely, be so severe as to incapacitate, usually for a relatively short period of time. Set and setting undoubtedly contribute to this type of reaction; that is, a person who expects some sort of severe mental dislocation is more likely to experience one; similarly, if he smokes marihuana in an unpleasant or frightening social setting he is more likely to react pathologically. Conversely, in a setting where use of marihuana as a recreational intoxicant is casual and well accepted and the smoker is experienced and comfortable, this type of adverse reaction is less probable. According to A. T. Weil, in communities where marihuana is well accepted as a recreational intoxicant, these reactions are extremely rare; they constitute about 1 percent of all responses to the use of marihuana in such settings. However, where use of the drug represents a greater degree of social deviance, as many as 25 percent of people using it for the first time may experience panic. 68 These reactions are self-limited, and simple reassurance is the best method of treatment. Perhaps the main danger of this type of reaction to the user (aside from the fact that it is quite uncomfortable) is that he will be diagnosed as having a toxic psychosis, an unfortunately common mistake.


Users with this kind of reaction, while they may be quite distressed, are not psychotic inasmuch as the sine qua non of sanity, the ability to test reality, remains intact, and the panicked user is invariably able to relate his discomfort to his use of the drug. There is no disorientation, nor are there "true" hallucinations.

Sometimes this panic reaction is accompanied by paranoid ideation. The user may, for example, believe that the others in the room, especially if they are not well known to him, have some hostile intentions toward him, or that someone is going to inform on him, often to the police, for smoking marihuana. Generally speaking, these paranoid-type ideas are not strongly held, and simple reassurance dispels them, Set and setting are again very important. Allen Ginsberg asserts that the anxiety and paranoid ideation are not so much a pharmacological effect as one determined largely by the fact that in the United States there is a real basis for them; here one can be apprehended for using marihuana and treated as a deviant criminal. 69 Curiously enough, as one peruses the psychiatric literature from different parts of the world, the emphasis on the anxiety-paranoia symptoms does not appear to be prominent in areas where penalties for the use of hemp are either nonexistent or not overly severe.

With respect to paranoia and the importance of set and setting, the following experience, reported by D. L. Farnsworth, is instructive. A student concerned about the widespread use of marihuana on his campus remonstrated to the dean against the lack of official action taken against those who were using the drug. The student said, "You have a list, you know, and why don't you get after the students who are smoking marijuana?" The dean denied that he had such a list, whereupon the student said, "You have one now," and gave the dean such a list. 70 The dean, concerned that he might be remiss in his duties if he did nothing, appointed a committee of faculty members and administrators to investigate the problem on campus, and shortly thereafter a student known to be selling drugs was apprehended. Because he feared that discussion of the case would violate the apprehended student's privacy, the dean refused to discuss the case and remained silent. However, his silence apparently increased the anxiety among those using marihuana; rumors about more lists and crackdowns ran throughout the campus. Among the rumors was one that the health services regularly turned over to the adminis-


tration the names of students using drugs. Despite the fact that no such betrayal was demonstrated and the punitive action on the part of the college authorities had been taken against only the one student supplier of drugs, fear and suspicion continued to spread. The patients at the health service who were already troubled and using drugs became increasingly guarded when talking with their psychotherapists, and within two weeks six patients became so paranoid that they required hospitalization. The usual rate for hospitalization at this particular college does not exceed two or three students per year.

Rarely, but especially among new users of marihuana, there occurs an acute depressive reaction which resembles the reactive or neurotic type. It is generally rather mild and transient but may sometimes require psychiatric intervention. This type of reaction is most likely to occur in a user who has some degree of underlying depression; it is as though the drug allows the depression to be felt and experienced as such. Again it must be supposed that set and setting play an important part, inasmuch as the same individual who on one occasion has this type of reaction will not have it on another occasion.

According to Weil, there are some rare reactions that occur in people who have previously taken "hallucinogenic" drugs. One is the recurrence of "hallucinogenic" symptomatology, the so-called "flashbacks." This type of reaction has been reported independent of marihuana use, and it usually consists of the recurrence of a "hallucination" first experienced during an earlier LSD or mescaline trip. However, and this too is quite clear, in some individuals a "flashback" may occur during a marihuana high. For some this is an enjoyable experience; for others it is distressing. Some see the "flashback" phenomenon as a specific instance of a more general change in the nature of the marihuana high, which may be experienced after the use of "hallucinogens." Generally this type of reaction fades with the passage of time. There is one report that is suggestive of the possibility of something like this reaction occurring in the absence of a prior history of use of "hallucinogens." 71

Quite rarely there are some people who, subsequent to their use of "hallucinogens," suffer psychotic reactions which may not become apparent until several months after the taking of a "hallucinogen." The reactions may appear unrelated to any previous


suggestion of mental illness, and in some cases they seem to have been precipitated by an acute marihuana intoxication. It is, of course, unknown whether they would have occurred without the use of marihuana. 72 Quite apart from any previous use of "hallucinogens," while it has not been conclusively established that marihuana may precipitate a psychosis, it stands to reason that a person maintaining a delicate balance of ego functioning - so that, for instance, the ego is threatened by a severe loss, or a surgical assault, or even an alcoholic debauch - may also be overwhelmed or precipitated into a schizophrenic reaction by a drug which alters, however mildly, his state of consciousness. The concatenation of factors - a person whose ego is already overburdened in its attempts to manage a great deal of anxiety and to prevent distortion of perception and body image, plus the taking of a drug which, especially in some individuals, seems to promote just these effects - may indeed be the last straw in precipitating a schizophrenic break. Of 41 acute schizophrenic patients studied by the author at the Massachusetts Mental Health Center, it was possible to elicit a history of marihuana use in 6. In 4 of the 6 it seemed quite improbable that the drug could have had any relation to the development of the acute psychosis, because the psychosis was so remote in time from the drug experience. Careful history taking and attention to details of the drug experience(s) and changing mental status in the remaining 2 patients failed to either implicate or exonerate marihuana as a precipitant in their psychoses.

Another peculiarity of the marihuana literature is that it is replete with claims that the long-term use of the drug leads to degeneracy. However, the few survey studies that exist, and are reasonably sound methodologically, generated data which fail to support this claim. One of the earliest was the report of the Indian Hemp Commission published in Simla in 1894 in the form of seven volumes comprising over 3,000 pages. As N. Taylor notes, there was suspicion that the real motive for the inquiry on the part of the British was to establish that Scotch whiskey, from which a large tax revenue could be derived, was less dangerous than hemp products. 73 Hemp products, with the exception of charas, were only about one-twentieth as expensive as whiskey and more difficult to tax. Nonetheless, the inquiry was carried out with typical British impartiality and meticulous examination


of 800 doctors, fakirs, yogis, coolies. superintendents of insane asylums, tax collectors, bhang peasants, clergy, hemp dealers, ganja palace operators, and so forth. They concluded as follows:
1. There is no evidence of any weight regarding mental and moral injuries from the moderate use of these drugs.
2. Large numbers of practitioners of long experience have seen no evidence of any connection between the moderate use of hemp drugs and disease.
3. Moderation does not lead to excess in hemp any more than it does in alcohol. Regular, moderate use of ganja or bhang produces the same effects as moderate and regular doses of whiskey. Excess is confined to the idle and the dissipated. 74
In the La Guardia study, 17 of the 77 subjects were chronic cannabis users. One can calculate from the data given (in Table 42 of that study) that the duration of usage ranged in these men from 21/2 to 16 years, with a mean of 8 years, and the number of cigarettes smoked per day varied from 2 to 18, with a mean of 7.2. 75 Despite the fact that this dosage would be considered to be rather on the high side of marihuana use in the United States, the investigators were able to establish that the marihuana users were not inferior in intelligence to the general population and that they had suffered no mental or physical deterioration as a result of their use of the drug. Nor could Freedman and Rockmore, whose 310 users had a history of an average of 7.1 years of cannabis use, find any evidence of mental or physical decline that could be attributed to drug use. 76 Furthermore, Bromberg's 67 criminal offenders who were users of marihuana revealed no peculiarities of psychopathology which would distinguish them from a non-marihuana-using group of criminal offenders. 77 Although in the study of Siler et al. the subjects were young (an average age of 23) and their experience in using the drug averaged only two years, it was also not possible to demonstrate any evidence of mental or physical deterioration. 78

Still, it is difficult to ignore the numerous reports from the East, particularly Egypt and parts of the Orient, which characterize the long-term cannabis user as a passive, nonproductive, even slothful degenerate. One possible explanation is that the excessive use of the stronger cannabis preparations may indeed lead to some physical and mental deterioration, as may the chronic excessive


use of alcohol and other substances. Another is that among whole populations that are already hungry, sick, and hopeless, there are many who have given up, are passive and nonproductive, and use relatively large quantities of an available and inexpensive drug to soften and distort the impact of an otherwise unbearable reality. A similar problem exists with regard to the "pot-heads" in the United States. Here again it is uncertain which comes first, the drug on the one hand or, on the other, the unbearable conflict, the depression or the personality disorder. D. L. Farnsworth cites six cases to illustrate the relationship of marihuana use to the development of emotional disturbance in college students, but in all of them serious conflict or depression existed well before the student began to use the drug. 79 In fact, it appears that the use of marihuana was one of the means these students tried for dealing with conflict, anxiety, and depression. Some of them took advantage of an opportunity to get psychotherapy, made good use of it, and had less need to use marihuana. However, it can be assumed that for many psychotherapy is not sought or is not available. Here the use of the drug is not causative, but symptomatic, and the conscious intent on the part of the user is not self-destructive, but restitutive.

It seems clear that among populations of illicit drug users there will be found more psychopathology than among nonusers. But the critical questions are whether the drug use comes first, and, if it does, whether it is causally related to the development of the psychopathology, either as a precipitating factor or a synergistic one, or whether the drug use is completely independent of the psychopathology or at the most an expression of it. Recently M. Cohen and D. F. Klein studied 70 patients who occasionally or frequently used "marijuana, amphetamines, barbiturates, LSD, other psychotogens, and opiates. 80 The 70 were among 224 consecutive in-patient voluntary admissions, under 25 years of age, to the Hillside Hospital between December 1966 and November 1967. All the 224 patients were hospitalized for nondrug reasons.

The patients were assigned to three groups:

1. An extreme drug-use group whose members indicated almost habitual use of two or more drugs on a daily basis for at least a one-month period; many had used drugs for several years. There were 39 patients in this group.


2. A moderate mixed-drug-use group composed of patients who made moderate use of two or more drugs or moderate to excessive use of only one drug, except marihuana. The 16 patients in this group used the drugs on an irregular basis, for instance, weekends or parties only.

3. A moderate marihuana-only group made up of those patients who had used only marihuana on either a regular or an irregular basis. The 15 patients in this group did not include those who had used the drug only once or twice.

In addition there was a nondrug control group selected from the non-drug-using patient sample and matched with the preceding groups for age and sex. 81

Of the demographic variables taken into account there were no significant differences between drug and control groups except for total WAIS IQ scores. Extreme drug-use patients had significantly higher scores (113.08) than either the moderate marihuana group (102.15) or the control group (103.26). The mean WAIS score for the moderate mixed-drug group (110.86) was close to that for the extreme group. Thus the authors found that the patient groups most involved with drugs were also the most intelligent. They also found that there were significantly more character disorders (85 percent) and fewer schizophrenic patients (5 percent) among the extreme drug-use patients than among any of the other three groups. The percentages of character disorders among the two moderate drug-use groups and the control patients were similar to those of the entire hospital population under 25 years of age (50-55 percent). Forty-five percent of the character disorders among the extreme drug-use group and 33 percent of those in the two moderate drug-use groups were found to be the "Emotionally Unstable" type as compared with 6 percent of the character disorders among the controls. Within the latter group, 44 percent of the character disorders were Passive-Aggressive/Dependent as compared with 30 percent among the extreme group and 18 percent among the combined moderate groups. "Combining all drug groups, there were significantly more Emotionally Unstable character disorders (21/51, 41%) among drug patients than among the controls (1/16, 6%, z = 3.76, p < .01); and significantly more passive-Aggressive/Dependent character disorders among the controls (7/16,44%) than among the drug patients


(13/51, 26%, z = 2.13, p <.05)." 82 The authors also demonstrated that there were significantly more psychotics among moderate drug users and controls than among the extreme drug users.

Two points should be emphasized regarding this study. First, neither the moderate mixed-drug-use group nor the moderate marihuana-only drug-use group had a higher prevalence of character disorders than did the control group or the entire hospital population under 25 years of age. (In fact an examination of the data in Table 3 of the study reveals that the percentage of character disorders among the moderate marihuana group was smaller than any other group and almost identical to that of the control group, 47 percent as compared with 46 percent; similarly, if one looks at the percentages for the prevalence of schizophrenia among the groups with the exception of the extreme drug group of 5 percent, the moderate marihuana group with 20 percent is lower than the other drug group and half that of the control group.) 83 Second, with respect to the extreme drug-use group, among which there is a higher prevalence of character disorders, there is no way of determining whether the extreme use of drugs in some way contributed to the existence of those disorders or whether, as seems more likely, people with this much and kind of psychopathology are more likely to use drugs and use them excessively.

That there are personality characteristics associated with the use of marihuana is becoming increasingly clear. R. Hogan et al., in a study of 148 male undergraduates at two universities, delineated some of these characteristics. The investigators defined three levels of marihuana use: (1) Users - students who reported that they had smoked or were still smoking marihuana; (2) Nonusers - students who reported that they had not smoked marihuana; and (3) Adamant nonusers - students who said that they had not and never would smoke marihuana. Through a biographical questionnaire and the California Psychological Inventory (a scale designed to measure "aspects of interpersonal behavior which arise in every day social living and are found in all cultures and societies"), they arrived at the following conclusions:

Users tended to major in the humanities and social sciences, and could be generally described as socially poised, open to experience, and concerned with the feelings of others. On the other hand they also tended to be impulsive, pleasure seeking,


and somewhat rebellious. In contrast, adamant non-users showed no clearly defined academic preferences, and were responsible and rule-abiding. However, they also tended to be rigid, conventional, and narrow in their interests. Finally, users and adamant non-users could not be distinguished in terms of a well-validated index of social maturity, and both groups appeared as less than morally mature on two scales designed to predict moral behavior. 84
The authors are careful to emphasize that these personality characteristics are merely associated with the use of marihuana and do not imply any causal relationship. However, there is no reason to suppose that the use of marihuana has any more to do with the personality traits associated with the user than its nonuse with those of the adamant nonuser. Unfortunately, the investigators do not distinguish between heavy and moderate users of marihuana.

A study that did compare heavy users with moderate users is the recent one of S. M. Mirin et al. They tested 12 "heavy users" (i.e., persons "using marihuana . . . 30 to 40 times per month") and 12 "casual smokers" (i.e., persons "using marihuana between 1 and 4 times per month") along a number of parameters; they obtained apparently paradoxical results from "two measures of hostility. . . . The Buss-Durkee Scale . . . [which is] a self-report of one's willingness to indulge in aggressive behavior," showed no significant difference between the two types with regard to general level of hostility, but the "Psychiatric Outpatient Mood Scale . . . [which is] an indicator of current mood," and which was administered at the end of the testing, indicated that "the group of heavy users scored significantly higher in hostility compared to the 'casuals' (p <.05; two-tailed t-test)." 85 The researchers offer several hypotheses to account for this apparent discrepancy: "the 'establishment' setting, the interviewers themselves, or the interview material. Casual users closely approximated the life style of their interviewers. In contrast, it is possible that discussion of multiple drug use coupled with questions about work, social and sexual adjustment [all of which were done prior to the Psychiatric Outpatient Mood Scale test] made our heavy users defensive, and then hostile." 86 Another finding of this same study, which confirmed other reports, was that "heavy marihuana use is frequently associated with use of more potent mind-altering agents." 87 The


authors, however, were careful to avoid concluding that "this data . . . implicate[s] marihuana as a cause of amphetamine or hallucinogen use." Instead, they tried to discover, "given this syndrome of multiple drug use and the preference of our Ss for marihuana . . . what it was in the marihuana experience that prompted its repetitive and frequent use. 88 They found that both the heavy and the casual users "cited the drug's pleasurable effects (i.e., euphoria, relaxation)" when questioned as to their reasons for continued drug use; "only the heavy users, however, mentioned the search for insight and/or the wish for a sense of harmony or union as part of their motivation for continuing." 89

The report concludes with the following statement: "Psychological dependence [which is not defined and which is attributed solely on the basis of the subjects' own reports] and the search for insight or a meaningful affective experience appear to be correlated with heavy marihuana use. Multiple drug use is also associated with poor work adjustment. Goal directed activity and the ability to master new problems is diminished. By traditional psychiatric standards, social adjustment in heavy users is poor as are their relationships with women. There is also evidence of a less than satisfactory sexual adjustment in this group." 90

When these findings are compared with an equally recent study by Zinberg and Weil, a somewhat different picture of the "chronic" marihuana user emerges: "Although we assigned them to the three groups - N, NN and C - the actual drug use of some of the NN [persons not naive to marihuana] approached that of the Cs [chronic marihuana users]. All but two in each of the three groups [the totals for each group were N - marihuana naive - 25; NN - 28; C - 9] were students in eight different institutions of higher learning in the Boston area. Of the rest, all but one (an N, diagnosed as a chronic schizophrenic . . .) were employed." 91 One interesting finding was that as marihuana use became more and more regular (or "chronic"), "the use of alcohol, especially distilled spirits, declined proportionately or even more steeply. . . . In the C group, with one exception, no subjects drank alcohol except as part of the marijuana smoking ritual when they sipped cold beer or wine to relieve dryness of the mouth. In fact, three of the nine C subjects virtually never drank alcohol, and one other reported a definite distaste for drink even before he started using marijuana." 92 The authors present the results


of their attempt to put each individual subject "on a rough gradient of personality traits ranging from extreme compulsiveness to extreme hysteria. The entire gradient is considered to fall within the limits of 'normal' character structures." 93 They predicted that persons tending toward hysteria would be more susceptible to the influence of marihuana, and the results of their interview-ratings bore out this prediction in an interesting fashion: "The N group showed a general tendency towards compulsiveness; the NN group tended towards more hysterical traits, and regular users (at least once a week) within the NN group clearly fell towards that end of the scale [i.e., hysteria]. Most subjects in both groups fell within the limits of the scale (that is, within the spectrum of normal personalities). By contrast, five of the nine C subjects fell off the scale and one more was only questionably within it. We shall call these personality distortions aberrations, although four of the six seemed well stabilized in their chosen environments." 94 They further noted that the C group was "easily differentiable from the other two" on a number of counts: they viewed their use of marihuana as the central and most significant aspect of their life-patterns; they showed a "constancy of attachment to female partners" that was "not only out of line with the rest of . . . [the] sample but significant compared with their age group in the general population or with a selected group matched for family background and educational achievement"; they displayed "extreme anxiousness and vague paranoia . . . during the interviews and persisting into the experiments." 95 However, they also note that "in appearance the C group split about fifty-fifty with five recognizably hippy (long-haired and costumed) and four 'clean-cut.' " Although two or three from each of the other two groups wore "unusual clothes, . . . none was as distinctive as the hippy members of the C group." 96

One of the more striking results of the report was purely unintentional: when the article was printed in Nature, an error of omission was made. Instead of the authors' statement: "There were no signs of overt intellectual deterioration in the C interviewees," the published article read as follows: "There were signs of overt intellectual deterioration in the C interviewees." 97 The Washington Post for 14 April 1970 ran a short article "summarizing" the report of Zinberg and Weil, with this lead headline: "Daily Pot-Smokers Erode in Intellect, Researchers Claim." 98 Since then Zinberg has publicly stated that the omission of the


crucial negative occurred somewhere in the publication process and was not omitted from the final draft submitted to Nature.

A final conclusion of the research was that the attitudes of the C group were "quite negative toward society, which they saw as blindly conformist." 99 In attempting to arrive at a valid explanation for these observed differences between the C and the other two groups, the research team considered three hypotheses, but felt that none was "satisfactory by itself: (a) the C group members . . . were generally more neurotic than the average person before they began using marihuana," and "it was their need to express some personality distortion . . . that pushed them into being chronic users of an illegal drug. (b) The Cs were 'weaker' [sic], more suggestible persons who had succumbed to heavy marijuana use, and the drug itself caused the distortions now observed. (c) Choice of marijuana as a means of self-expression marks one as a deviant in the eyes of society and leads to fear of the police and other agents of the prevailing social order. Impact of these experiences on the C group produced the personality changes recorded in the interviews." 100 The members of the C group preferred to think that the last of the three proposed hypotheses was the correct one, and even "saw it as a factor in their early decisions to marry. They were uniformly bitter about society's attitude toward marijuana use and said this feeling affected their lives. Many reported that being defined as a deviant and law-breaker for something they could not accept as criminal had driven them into increasingly negative attitudes toward the larger society. Three subjects were especially articulate in tracing the shift of their values that led them to seek out individuals and groups who shared their positions and who used marijuana as frequently." 101 The contentions of these members of the C group are bolstered by the observation that "although 60 percent of the NN subjects were regular users, all began use after 1966 while all the Cs began use before 1965. The social atmosphere at the time that the NNs began to use marijuana accepted the use more thoroughly, contemporaries were less likely to differentiate people as special (rebels or heroes) simply because of the drug use." 102

One completely unexpected finding surprised the investigators, since it contradicted a number of earlier studies (see note 87, above): "A negative finding that deserves some attention . . . was the low frequency of use of drugs other than cannabis in the NN and C groups. . . . if a single experiment with a drug


('one taste') is disregarded, then only 20 per cent have used any drug other than cannabis. [It is not clear if alcohol is included as a drug here.] And in those two cases (LSD and mescaline twice, and LSD three times) the use of these drugs was seen as a careful intellectual or philosophical exercise and was repeated ostensibly only for that purpose." 103

In closing, the authors return to a discussion of alcohol and cannabis: "In the case of the moderate use of alcohol associated with late adolescence and the early twenties, marijuana smoking seems to be a functional equivalent, not simply a further drug habit. . . . Possibly, a history of initial and persistent dislike of alcoholic effect will turn out to be correlated with subsequent chronic marijuana use." 104

In a survey of drug use on two eastern campuses, E. S. Robbins et al. administered a self-rating questionnaire in the classroom to 287 students, all but 1 of whom completed it. The investigators recognized the limitations of this sample, because it did not include absentees and drop-outs. From their data they characterized a typical marihuana user as "a liberal arts student, who reported somewhat looser religious ties than his non-drug-using classmates. Many marihuana users classified themselves as agnostics or atheists, or reported preferring an Eastern religion such as Zen to the one their parents professed. Half the marihuana smokers expressed dissatisfaction with their school, in contrast to 20 percent of the nonusers." 105

The data from their self-assessment personality scale revealed that the drug user (meaning those who used illicit substances such as marihuana, LSD, and heroin or medicines such as amphetamines or barbiturates) "described themselves as usually anxious, bored, cynical, disgusted, impulsive, moody, rebellious, and restless significantly more often than did nonusers. They also saw themselves as never ambitious, secure, or slow. The nonusers were much more positive in their self-reports, selecting ambitious, contented, decisive, and secure as traits that usually depicted them. They felt that they were never helpless, hopeless, lonely, useless, or worthless significantly more often than the drug users." 106 The authors note that the marihuana smokers tended to describe themselves as more moody and unhappy than the nonsmokers and considered that the differences might be due to a greater tendency to "respond along conventional, socially ac-


ceptable lines on the part of the nonusers of marihuana. The marihuana smokers might have been responding in terms of quite different norms than their classmates, with their ideal image more likely that of a searching, self-preoccupied, and restless individual.

Within the context of this study, it is not possible to determine whether the marihuana smokers were more tense than the others when they began to smoke, or whether smoking made them more moody and depressed." 107 A. Braiman, in discussing this paper, noted that K. Keniston had previously remarked that "alienated students are quick to admit their confusions, angers, anxieties, and problems. Given a list of neurotic symptoms, they check them all, describing themselves as socially undesirable, confused, depressed, angry, neurotic, hostile and impulsive." 108 For this reason Keniston is cautious in interpreting the self-descriptions as realistic barometers of psychopathology:

The inference that these students are grossly disturbed can only be made with reservations. For one, they reject the value assumptions upon which most questionnaire measures of "maturity," "ego-strength," and "good mental health" are based. Furthermore, they make a great deal of effort to undermine any so-called "defenses" that may protect them from unpleasant feelings. For most of these students, openness to their own problems and failings is a cardinal virtue, and they make a further point of loudly proclaiming their own inadequacies. 109
There are some striking parallels between personality traits of cigarette smokers and marihuana users. C. McArthur et al. have studied for almost twenty years "252 Harvard alumni [from the classes of 1938 and 1942] who were selected during their sophomore years for lack of visible abnormality" in an attempt to delineate a psychology of smoking. 110 Of this work they write:
In summary, then, we may hypothesize that starting to smoke is largely brought about by one's social environment but that reactions to smoking, once it has started, seem to depend in good part on the personal needs that the newly-established habit is able to gratify. Some people seize on the habit compulsively. These people may often be emotionally constricted types for whom there is great gain in a simple "flight into


behavior" or they may be restless, active men, for whom smoking is just one more impulsive activity. It would also seem that anxious people can seize on smoking as a tension reducer if they have already, for other reasons, been oriented toward it. In short, the habit, once well available, increases in strength if it serves well the person's emotional economy. 111
If one looks at the "psychiatric labels" which describe their "heavier smokers" who cannot stop smoking, they are close to those one would imagine might popularly be applied to a group of heavy marihuana users: "Weak Basic Personality, Asocial, Lack of Purpose and Values, Introspective, Ideational, and Inhibited." 112 In another paper they state, "Within the smoking group, one can make a case for the poorer integration of the heavy smoker's personality. The heavy smokers are often given to what the psychiatrists call 'acting out.' " 113

In a more recent study (involving Harvard freshmen from the classes of 1958 and 1961) it was found, with respect to the examining physicians' ratings on "Personality Integration," that "the percentage of smokers marches upwards as the ratings become less favorable." 114 Similarly, in relation to the examining physicians' prediction of "College Adjustment," percentages are again related to predictions of poorer adjustment: "Both these findings from the physicians' ratings would seem to parallel the study findings that smoking went with psychiatric ratings suggesting poorer mental health." 115 What is so strikingly different in this paper is that, unlike those which deal with the association of personality traits and the use of marihuana, there is no hint or implication that cigarette smoking may be in any way responsible for the psychopathology described.

Of the various personality changes that allegedly occur with the chronic use of cannabis, those which together constitute what has been called the "amotivational syndrome" have been written about by several authors. 116 Those who suffer from this "syndrome" are described as being passive, nonproductive, achievement-eschewing, sloven, apathetic, and ineffective. It has even been suggested that those who use marihuana regularly may be "actually performing chemical self-leukotomies," that is, destroying areas of the frontal lobes of the brain which when accomplished surgically leaves "the individual more comfortable but less able to carry out


complex long-term plans, endure frustration, concentrate for extended periods, follow routines, or successfully master new material (learning) with the same ease as before." 117 The description of the "amotivational syndrome" is based on some clinical observations in which no attempt has been made to distinguish between preexisting personality traits and this particular alleged sequela of chronic cannabis use.

W. H. McGlothlin and L. J. West, in a paper titled "The Marihuana Problem: An Overview," assert that "clinical observations indicate that regular marihuana use may contribute to the development of more passive, inward-turning, amotivational personality characteristics. For numerous middle-class students, the subtly progressive change from conforming, achievement-oriented behavior to a state of relaxed and careless drifting has followed their use of significant amounts of marihuana." 118 Yet in another paper, "Flight from Violence: Hippies and the Green Rebellion," in the same issue of the American Journal of Psychiatry, West and Allen, attempting to establish a close relationship between hippies and the use of marihuana, describe the following four "stages of hippiedom":

The hippie way of life apparently evolves with the individual's passage through a series of stages that may be listed as follows:
Step 1: Dissatisfaction and frequently a sense of impotence in dealing with the world, usually symbolized by one's middle-class parents. While our subjects ranged in age from 17 to 52, the vast majority of the hippies were intelligent. college-educated 20-year-olds of white middle-class background, from which they were trying to escape - less with a feeling of anger than with disillusionment and the sad conviction that their parents were unable to offer relevant models of competence These were mostly thoughtful, sensitive youngsters with liberal, idealistic values - values perhaps articulated but not necessarily practiced by their parents.
Step 2: A search for meaning in the light of a good educational background and from an initial posture of financial - not interpersonal - security. The search was directed toward the Haight-Ashbury by the mass media, hot and cool, establishment and underground. They supplied guidebooks and manufactured stereotypes for the youth to live out.


Step 3: Association with other searchers, some of whom seemed to have discovered a Way.
Step 4: Turn on (with drugs). Tune in (on the hip scene). Drop out (from the competitive life of society). 119
It is not difficult to imagine that an adolescent with an inchoate adult identification who has truly passed through the first three stages of this Odyssean schema would appear different in his orientation to life and his behavior whether or not he had ever used marihuana. Inward-turning young people who have embraced such a profound rejection of the life style of their goal-oriented, achievement-seeking, well-dressed, and materially secure parents may very well adopt, in most cases transiently, an identification and style of living that is shared by a large group of their peers, a style in which they present themselves as passive, nonproductive, and sloven. There is, then, the question whether the "amotivational syndrome," assuming for the moment that it is a clinical reality, is necessarily a product of the chronic use of cannabis; and beyond that, there is the question whether or not this syndrome is truly a manifestation of personality deterioration or even change.

Personality has been defined in a multitude of ways. A psychodynamic approach sees personality as evolving over time and within the limits of genetic potentials through a prolonged series of stages of social experiencing into a system of more or less enduring and consistent attitudes, beliefs, desires, capacities for affective expression, and patterns of adaptation, which make each individual unique. The distinctive whole formed by these relatively permanent patterns and tendencies of a given person is spoken of as his personality. Once it is fully formed it is rather resistant to change; even a profound experience like psychoanalysis, one which is calculated to effect personality change, very often leads to limited differences, and they are often so subtle that they elude attempts at objectification and quantification. There can be no doubt that certain personality types are more attracted to the use of marihuana, but it is questionable whether its use, certainly its moderate use, leads to personality change. I think however, that of all the deleterious effects which cannabis use is alleged to cause, personality change, especially with regard to heavy use, is the most difficult to refute. Data from well-designed, prospective,


longitudinal studies which bear directly on this point are simply not available at this time.

As has been noted, there are clinicians who have reported what they discern as personality change, and they relate this to the use of cannabis. I would agree that when a young person gives up a more or less conventional mode of living for one which is or is closer to that of the hippie, one may observe in him changes in behavior and attitude, changes which, taken together, may constitute what has been called the "amotivational syndrome." I am not so certain, however, that these differences constitute personality change; it may be more accurate to consider them manifestations of a purposeful and extensive change in life-style, one involving ideology, values, attitudes, dress, social norms, and many aspects of behavior. This type of change may be likened to that which a girl who decides to join a convent may undergo; she certainly appears different with respect to her values, dress, goals, behavior, and so forth, but beneath her habit the same pre-convent personality resides. Similarly, it seems more than likely that behind the hirsuteness and the hip patinas are personalities which have not undergone significant arid basic change.

The use of marihuana is almost always one manifestation of this kind of change in life-style; whether it may also contribute in some way to the change is unknown. However, it appears that the determinants of this type of change are more likely to be found in predisposing personality problems and in disaffection with the social system than in the moderate social use of the drug marihuana.

[End of Chapter 10]


Notes to Pages 247-254


1. J. H. Tull-Walsh, "Hemp Drugs and Insanity," J. Ment. Sci., 40 (1894), 21-36. He cites A. Simpson, "Annual Report Dacca Lunatic Asylum for 1862"; A Fleming, "Annual Report Moorshedabad Lunatic Asylum, 1862"; J. McClelland, Officiating Principal Inspector General Medical Department, "Annual Report on Lunatic Asylums, Bengal, 1863"; A. Simpson, "Annual Report Dacca Lunatic Asylum for 1863"; W. B. Beatson, "Annual Report Dacca Lunatic Asylum for 1864"; R. F. Hutchinson, "Annual Report Patna Lunatic Asylum for 1865"; A. Eden, "Government Resolution, 1866"; N. Jackson, "Annual Report Cuttack Lunatic Asylum for 1866"; J. Wise, "Annual Report Dacca Lunatic Asylum for 1867"; H. C. Cutcliffe, "Annual Report Dacca Lunatic Asylum for 1869"; W. D. Stewart, "Annual Report Cuttack Lunatic Asylum for 1867"; J. D. Wise, "Annual Report Dacca Lunatic Asylum for 1868"; R. F. Hutchinson, "Annual Report Patna Lunatic Asylum for 1868"; A. J. Payne, "Annual Report Dallanda Lunatic Asylum for 1871"; A. Mackenzie, "Government Resolution on Asylum Report, 1871"; J. Campbell Brown, Inspector General of


Notes to Pages 254-259

Hospitals, Bengal, "Annual Report on Asylums, 1872"; J. Wise, "Annual Report Dacan Lunatic Asylum for 1872."

2. R. P. Walton, Marijuana, America's New Drug Problem (Philadelphia, 1938), p. 142.

3. A. Eden, "Government Resolution, 1866," in Tull-Walsh, "Hemp Drugs and Insanity," p. 25.

4. A. Simpson, "Annual Report Dacca Lunatic Asylum for 1863," in Tull-Walsh, "Hemp Drugs and Insanity," p. 24; H. C. Cutcliffe, "Annual Report Dacca Lunatic Asylum for 1869," in Tull-Walsh, "Hemp Drugs and Insanity," p. 30.

5. G. F. W. Ewens, "Insanity Following the Use of Indian Hemp," Indian Med. Gaz., 39 (1904), 404.

6. R. F. Hutchinson, "Annual Report Patna Lunatic Asylum for 1865," in Tull-Walsh, "Hemp Drugs and Insanity," p. 25.

7. Ibid., citing A. Simpson, "Annual Report Dacca Lunatic Asylum for 1862"; A. Fleming, "Annual Report Moorshedabad Lunatic Asylum, 1862"; A. Eden, "Government Resolution, 1866"; R. F. Hutchinson, "Annual Report Patna Lunatic Asylum for 1868"; J. Coates, "Annual Report Moydapore Lunatic Asylum for 1871"; A. MacKenzie, "Government Resolution on Asylum Reports, 1871"; J. Wise, "Annual Report Dacan Lunatic Asylum for 1872."

8. A. J. Payne, "Annual Report Dallanda Lunatic Asylum for 1871," in Tull-Walsh, "Hemp Drugs and Insanity," p. 30.

9. Ibid.

10. J. Wise, "Annual Report Dacan Lunatic Asylum for 1872," in Tull-Walsh, "Hemp Drugs and Insanity," p. 32.

11. Tull-Walsh, "Hemp Drugs and Insanity," p. 34.

12. A. MacKenzie, "Government Resolution on Asylum Reports, 1871, Bengal," in Tull-Walsh, "Hemp Drugs and Insanity," p. 31.

13. J. Warnoch, "Insanity from Hasheesh," J. Ment. Sci., 49 (1903), 101-102.

14. J. E. Dhunjibhoy, "A Brief Resume of the Types of Insanity Commonly Met with in India, with a Full Description of Indian Hemp Insanity Peculiar to the Country," J. Ment. Sci., 76 (1930), 263.

15. Walton, Marihuana, p. 147.

16. Warnoch, "Insanity from Hasheesh," pp. 99-100.

17. A. Benabud, "Psycho-pathological Aspects of the Cannabis Situation in Morocco: Statistical Data for 1956," Bull. Narcotics, 9 (1957), 2-16.

18. The existence of this particular type of psychosis has been seriously questioned. See J. F. Siler et al., "Marihuana Smoking in Panama," Milit. Surg., 73 (1933), 269-280; J. R. Bouquet, "Cannabis," Bull. Narcotics, 3 (1951), 22-45; and A. Porot, "Le cannabisme," Ann. Medico-psychol., 1 (1942), 1-24.

19. H. B. M. Murphy, "The Cannabis Habit: A Review of the Recent Psychiatric Literature," Addictions, 13 (1966), 13 (citing R. N. Chopra and G. S. Chopra, "The Present Position of Hemp Drug Addiction in India," Indian Med. Res. Mem., 31 .(1939).

20. Lin Tsung-yi and C. C. Standley, "The Scope of Epidemiology in Psychiatry," Public Health Papers, 16 (1962), 9-76.

21. Ewens, "Insanity Following Use of Hemp," p. 404.

22. Warnoch, "Insanity from Hasheesh," p. 109.

23. Tull-Walsh, "Hemp Drugs and Insanity," p. 35.


Notes to Pages 260-267

24. W. Grossman, "Adverse Reactions Associated with Cannabis Products in India," Ann. Intern. Med., 70 (1969), 532.

25. Ibid.

26. Tull-Walsh, "Hemp Drugs and Insanity," p. 23.

27. Warnoch, "Insanity from Hasheesh," p. 109; A. Boroffka, "Mental Illness and Indian Hemp in Lagos," E. Afr. Med. J., 43 (1966), 377-384.

28. Tull-Walsh, "Hemp Drugs and Insanity," pp. 34-35.

29. Ibid., p. 36.

30. J. Wise, "Annual Report Dacan Lunatic Asylum for 1872," in Tull-Walsh, "Hemp Drugs and Insanity," p. 32.

31. W. Keup, "Psychotic Symptoms Due to Cannabis Abuse," Dis. Nerv. Syst., 30 (1970), 119.

32. H. S Becker, "History. Culture and Subjective Experience: An Elaboration of the Social Bases of Drug-Induced Experiences," J. Health Soc. Behav., 8 (1967), 172.

33. H. L. Freedman and M. J. Rockmore, "Marihuana: A Factor in Personality Evaluation and Army Maladjustment," J. Clin. Psychopathology, 7 (1946), 765-782, and 8 (1946), 233.

34. S. Charen and L. Perelman, "Personality Studies of Marihuana Addicts," Amer. J. Psychiat., 102 (1946), 674-682.

35. H. S. Gaskill, "Marihuana, an Intoxicant," Amer. J. Psychiat., 102 (1945), 204.

36. Siler et al., "Marihuana Smoking in Panama," p. 278.

37. S. Allentuck, "Medical Aspects: Symptoms and Behavior," in Mayor's Committee on Marihuana, The Marihuana Problem in the City of New York (Lancaster, Pa., 1944), pp. 45-51.

38. S. Allentuck and K. M. Bowman, "The Psychiatric Aspects of Marihuana Intoxication," Amer. J. Psychiat., 99 (1942), 249.

39. W. Bromberg, "Marihuana, A Psychiatric Study," J.A.M.A., 113 (1939), 4-12.

40. H. B. M. Murphy, "The Cannabis Habit: A Review of Recent Psychiatric Literature," Bull. Narcotics, 15 (1963), 12.

41. D. Perna, "Psychotogenic Effect of Marihuana," J.A.M.A., 209 (1969), 1086.

42. G. D. Klee, "Marihuana Psychosis: A Case Study," Psychiat. Quart., 43 (1969), 719.

43. Ibid., p. 720.

44. Ibid., pp.720-725.

45. Ibid., p. 727.

46. Ibid.. pp. 727-728.

47. Ibid,. p. 730.

48. P. Dally, "Undesirable Effects of Marijuana," Brit. Med. J., 3 (1967), 367.

49. Ibid.

50. Ibid.

51. Ibid.

52. Ibid.

53. J. A. Talbott and J. W. Teague, "Marihuana Psychosis: Acute Psychosis Associated with the Use of Cannabis Derivatives," J.A.M A., 210 (1969), 301.


Notes to Pages 267-281

54. Ibid., p. 302.

55. W. J. Tiffany, Jr., "The Mental Health of Army Troops in Viet Nam," Amer. J. Psychiat., 123 (1967), 1585-1586.

56. Personal correspondence.

57. Murphy, "Cannabis Habit," p. 14.

58. L. J. Hekimian and S. Gershon, "Characteristics of Drug Abusers Admitted to a Psychiatric Hospital," J.A.M.A., 205 (1968), 125-130.

59. Keup, "Psychotic Symptoms," p. l20.

60. Ibid., p. 125.

61. D. E. Smith, "Acute and Chronic Toxicity of Marijuana," J. Psychedelic Drugs, 2 (1968), 41.

62. H. Isbell et al., "Studies on Tetrahydocannabinol," Bull. Probl. Drug Dependence (1967), p. 4838.

63. Ibid.

64. Ibid.

65. Ibid., p. 4833.

66. Becker, "History, Culture and Subjective Experience," pp. 168-169.

67. S. C. McMorris, "What Price Euphoria?: The Case Against Marihuana," Medicoleg. J., 34 (1966), 78.

68. A.T. Weil, "Adverse Reactions to Marihuana," New Eng. J. Med., 282 (1970), 998.

69. A. Ginsberg, "The Great Marijuana Hoax: First Manifesto to End the Bringdown," Atlantic Monthly, Nov. 1966, p. 109.

70. D. L. Farnsworth and T. W. Scott, "Marijuana: The Conditions and Consequences of Use and the Treatment of Users," in Drugs and Youth: Proceedings of the Rutgers Symposium on Drug Abuse, ed. J. R. Wittenborn et al. (SpringfieId, Ill., 1969), p. 172.

71. M. H. Keeler, "Adverse Reaction to Marihuana," Amer. J. Psychiat., 124 (1967), 674-677.

72. Weil, "Adverse Reactions to Marihuana," pp. 999-1000.

73. N. Taylor, Narcotics: Nature's Dangerous Gifts (New York, 1963), p. 26.

74. N. Taylor, "The Pleasant Assassin: The Story of Marihuana," in The Marihuana Papers, ed., D. Solomon (Indianapolis, 1966), p. 11.

75. Mayor's Committee, The Marihuana Problem, pp. 142-143.

76. Freedman and Rockmore, "Marihuana: Factor in Personality Evaluation," pp. 7, 765-782; 8, 221-236.

77. Bromberg, "Marihuana: A Psychiatric Study," pp. 4-l2.

78. Siler et al., "Marihuana Smoking in Panama," pp. 269-280.

79. D. L. Farnsworth, "The Drug Problem among Young People," presented at the Centennial Meeting of West Virginia State Medical Association in White Sulphur Springs, W. Va., Aug. 25, 1967.

80. M. Cohen and D. F. Klein, "Drug Abuse in a Young Psychiatric Population," Amer. J. Orthopsychiat., 40 (1970), 449.

81. Ibid., p. 450.

82. Ibid., pp. 452-453.

83. Ibid., p. 452 (Table 3).

84. R. Hogan et al., "Personality Correlates of Undergraduate Marijuana Use," paper presented at the Spring Meetings of the Eastern Psychological Association, Philadelphia, 1969. Quotation from preprint, p. 8.

85. S. M. Mirin et al., "Casual versus Heavy Use of Marihuana: A Redefi-


Notes to Pages 281-287

nition of the Marihuana Problem," Psychopharmacology Laboratory, Division of Psychiatry, Boston University School of Medicine, Boston, Mass., 1970, p. 9 (preprint).

86. Ibid., p. 13.

87. See, e.g., E. Goode, "Multiple Drug Use Among Marijuana Smokers," Social Problems, 17 (1969), 60-61; F. W. King. "Marijuana and LSD Usage Among Male College Students: Prevalence Rate, Frequency, and Self-Estimates of Future Use," Psychiatry, 32 (1969), 265-276; J. D. Hensela, L. J. Epstein, and K. H. Blacker, "LSD and Psychiatric Inpatients," Arch. Gen. Psychiat., 16 (1967), 554-559.

88. Mirin et al., "Casual versus Heavy Use of Marihuana," p. 10.

89. Ibid., p. 11.

90. Ibid., p. 14.

91. N. E. Zinberg and A. T. Weil, "A Comparison of Marijuana Users and Non-Users," Nature, 226 (1970), 119.

92. Ibid., p. 120.

93. Ibid.

94. Ibid., pp. 120-121.

95. Ibid., p. 121.

96. Ibid., p. 122.

97. Ibid.

98. A. Friendly, "Daily Pot-Smokers Erode in Intellect, Researchers Claim," Washington Post, April 14, 1970.

99. Zinberg and Weil, "Comparison of Marijuana Users and Non-Users," p. 122.

100. Ibid.

101. Ibid.

102. Ibid.

103. Ibid.

104. Ibid., p. 123.

105. E. S. Robbins et al., "College Student Drug Use," Amer. J. Psychiat., 126 (1970), 88.

106. Ibid., p. 90.

107. Ibid., p. 91.

108. K. Keniston, "Alienation in American Youth," paper presented at the Annual Convention of the American Psychological Association, New York, Sept. 4, 1966. Braiman's discussion followed the paper.

109. Ibid.

110. C. McArthur, E. Waldron, and J. Dickinson, "The Psychology of Smoking," J. Abnorm. Soc. Psychol., 56 (1958), 267.

111. Ibid., p. 272.

112. Ibid.

113. C. C. McArthur, "The Personal and Social Psychology of Smoking," in Tobacco and Health, ed. G. James and T. Rosenthal (Springfield, Ill., 1962), p. 294.

114. McArthur et al., "Psychology of Smoking," p. 274.

115. Ibid.

116. J. Kaufman, J. R. Allen, and L. J. West, "Runaways, Hippies, and Marihuana," Amer. J. Psychiat., 126 (1969), 717-720; L. J. West and J. R. Allen, "Three Rebellions: Red, Black, and Green," in The Dynamics of Dissent: Scientific Proceedings of the American Academy of


Notes to Pages 288-297

Psychoanalysis,. ed. Jules H. Masserman, (New York, 1968), pp. 99-119; J. R. Allen and L. J. West, "Flight From Violence: Hippies and the Green Rebellion,' Amer. J. Psychiat., 125 (1968), 364-370; W. H. McGlothlin and L. J. West, "The Marihuana Problem: An Overview," Amer. J. Psychiat., 125 (1968), 126-134; Benabud, "Psycho-pathological Aspects," pp. 10-16.

117. Allen and West, "Flight from Violence," p. 369; West and Allen, "Three Rebellions," p. 110.

118. McGlothlin and West, "Marihuana Problem," p. 128.

119. Allen and West, "Flight from Violence," p. 366.



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