Contents
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
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
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-
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
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
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:
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
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
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.
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
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,"
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-
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-
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:
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
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-
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-
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:
It is difficult to understand how, in the face of all the evidence to the contrary, prominent medical men, newspaper reporters,
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
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.
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-
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
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
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
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.
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
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:
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
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
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
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
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-
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:
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
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":
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,
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.
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
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Notes to Pages 254-259
Hospitals, Bengal, "Annual Report on Asylums, 1872"; J. Wise, "Annual Report Dacan Lunatic Asylum for 1872."
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