cannabis poisoning

SATURDAY CLINICAL MEETING
Presented by Sqn Ldr CS Bharath
Resident in Psychiatry
Moderated by Lt Col Amitabh Saha
Asst Prof in Psychiatry
DEPARTMENT OF PSYCHIATRY, AFMC19 Nov 2016

PATIENT INTRODUCTION
 19 year old son of Officer
 Hails from Delhi
 Studying BSc Economics at Symbiosis College
Pune
19/11/2016DEPT OF PSYCHIATRY

REASON FOR REFERRAL
 Was referred by AMA as he had become
 Irritable and aggressive
 Had begun to talk excessively and irrelevantly
 Believed that someone was tracking his movements
 Against the background of stopping cannabis use
6 days ago
 Transferred to CH(SC): 27 Oct 2016

INFORMANTS
 Informant Reliability
 Self Poor
 Father Fair
 Mother Fair

19/11/2016
 Closeness of relationship of the informant to
patient
 Informant has no obvious conflict of interest
with patient
 Informants presence during the occurrence of
phenomenon
How do you assess reliability of
information?
DEPT OF PSYCHIATRY

How do you assess reliability of
information?
19/11/2016
 Status of Insight of patient
 Presence of Co-morbid ailments like
 Substance use disorders
 Antisocial personality disorder
 Any legal implications
 Impairment in memory may be there:
Confabulation, dissociation
Contd…
Ref: Kaplan & Sadock’s CTP. 9th
Ed 2009. Pg 926
DEPT OF PSYCHIATRY

CHIEF COMPLAINTS
 Regular use of cannabis
 Disturbed sleep
 Overtalkativeness
 Irritability
 Belief that a family member
was trying to control him and
-his family members through
Facebook and Whatsapp
3 Years
19/11/2016
4 Days
5 Days
DEPT OF PSYCHIATRY

HISTORY OF PRESENT ILLNESS
19/11/2016
 Started smoking cannabis at the age of 16 years,
during 11th
std under peer influence
 Initially smoked 2-3 puffs, felt relaxed, light headed,
improved mood, “music sounded better, things started
making sense”
 Thereafter, smoked one ‘joint’ once a week with
school friends
 After a year, entered BSc Economics in an acclaimed
college in Pune, smoked a ‘joint’ thrice a week
 Would reduce his “irritability and tension”
 Had made 2-3 attempts to reduce smoking, but had
failed due to irresistible desire
DEPT OF PSYCHIATRY

What is Craving ?

What is Craving ?
19/11/2016
 A strong desire or urge to use the substance
Diagnostic & Statistical Manual, 5th
Edition
DEPT OF PSYCHIATRY

19/11/2016
 Increased his smoking to 2 joints thrice a week
in the peer group of friends on the basketball
team 1 year ago, introduced the drug to
novices
 Performance began to fall, attendance
dropped and he failed in 3 of his eight 2nd
semester subjects 8 months ago
 At about the same time began to smoke daily,
5-6 joints.
DEPT OF PSYCHIATRY

 After losing a basketball match, patient was
dismayed and his level of cannabis intake
increased
 ‘Graduated’ to “Bong” usage to enhance the
“hit”
 After his 3rd
semester exams on 22 Oct 16, quit
smoking suddenly as he was going to visit his
parents in a few days

What is ‘Bong’?

BONG

What are the different ways of
consuming Cannabis?

What are the different ways of
consuming Cannabis?
 Respiratory route :
 Hand rolled cigarettes or “joints”
 Readymade “chillums”
 Water bongs or pipes or “hookah”
 Inhalation of heated “hashish oil” vapours
 Oral route :
 “Hashish” baked in brownies or cookies
 THC dissolved in sesame oil as Gelatin capsules
 Cooked in the form of “bhaang”
 Dried powder or “Hashish balls” downed with water

What are the signs & symptoms of
Cannabis intoxication ?

What are the signs & symptoms of
acute Cannabis Intoxication ?
 Physical
 Tachycardia
 Postural hypotension
 Conjunctival injection
 Dry mouth
 Increased appetite
 Cognitive
 Suspiciousness or
Paranoid ideation
 Impaired judgment
 Impaired Attention
 Impaired Reaction Time
 Affective
 Euphoria
 Disinhibition
 Anxiety
 Perceptual
 Temporal Slowing
 Auditory, Visual or
Tactile Illusions or
Hallucinations
 De-personalisation &
De-realisation

What is Tolerance ?

What is Tolerance ?
19/11/2016
 Tolerance is defined by either of the following:
 Need for markedly increased amounts of the
substance to achieve intoxication or desired effect
 Markedly diminished effect with continued use or
the same amount of the substance
Kaplan & Sadock’s CTP. 9th
Ed 2009. Pg 928
DEPT OF PSYCHIATRY

Dependence criteria for addiction?
19/11/2016
 A strong desire or sense of compulsion to take the
substance
 Impaired capacity to control substance-taking behaviour in
terms of onset, termination or level of use
 Physiological withdrawal state when substance use is
reduced or ceased
 Evidence of tolerance to the effects of the substance
 Preoccupation with substance use, as manifested by
 Giving up important alternative pleasures or interests
 Great deal of time spent in activities necessary to obtain the
substance, take the substance, or recover from its effects
 Persisting with substance use despite clear evidence of
harmful consequences
World Health Organization. (1992). The ICD-10 classification of mental and behavioural
disorders: Clinical descriptions and diagnostic guidelines.
DEPT OF PSYCHIATRY

INSOMNIA
Started the day after stopping cannabis
Insidious onset and progressive in nature
Significant initiation and maintenance difficulty
Spent hours on Whatsapp and Facebook
Slept for 2-3 hours in the whole day since last 05
days

 h/o persistent irritability during the day gradually
progressive since last 5 days
 Had numerous arguments with classmates over
trivial issues, unlike his usual self

What are the features of Cannabis
Withdrawal?

What are the features of Cannabis
Withdrawal?
 ‘Physical Symptoms’
 Headache
 Chills
 Stomach Pain
 Sweating
 Tremors
 Sleep difficulty
(Insomnia or
disturbing dreams)
 Decreased appetite or
Weight loss
 ‘Mental Symptoms’
 Depressed mood
 Restlessness
 Irritability
 Anger or Aggression
 Craving for Cannabis
 Anxiety

19/11/2016
 Against the background of increased usage of
Facebook and Whatsapp, began to believe that a
cousin of his was plotting to harm him and his
parents via social media
 Unable to describe exactly how he concluded so
 Called his father to warn about his nefarious
designs, advised against using mobile phones to
avoid being harmed
 The father sensed something was wrong and flew
to Pune immediately
DEPT OF PSYCHIATRY

What is this symptom?
19/11/2016
 Made statements like:
 “My cousin is tracking my every move, and I am
sure he will harm me and my parents ”
DEPT OF PSYCHIATRY

Delusion

What is a delusion?

What is a Delusion ?
19/11/2016
 Firm or unshakable belief
 Held on inadequate grounds
 Despite evidence to the contrary
 Not in keeping with the person’s educational,
social and cultural background
DEPT OF PSYCHIATRY
Ref: Kaplan & Sadock’s CTP. 9th
Ed 2009

CLASSIFY DELUSIONS

SUBSTANCE USE
19/11/2016
 h/o recreational use of cigarettes 1-2 times/
months for past 03 years
 Drinks 3-4 units of alcohol once in a few
months followed by a period of abstinence
 Nondependent on either
DEPT OF PSYCHIATRY

What is a Gateway Drug?

What is a Gateway Drug?
19/11/2016
 Less dangerous drug that precedes, and can
lead to, future use of more dangerous hard
drugs
 Eg. Tobacco, Cannabis, Alcohol
DEPT OF PSYCHIATRY

NEGATIVE HISTORY
 No h/o-
 Persistent pervasive low or high mood
 Suicidal thoughts/ attempts
 No h/s/o perceptual abnormality
 No h/o Head injury/ Seizure/ Loss of
consciousness

PAST HISTORY
 No h/o any other medical illness of significance

FAMILY HISTORY
19/11/2016
 Middle Class (Defence) household hailing Delhi
 Cordial relation with family members
 h/s/o Bipolar Affective disorder in maternal uncle
 No h/o any other medical or psychiatric illness in
family
55
19
52
24
55
DEPT OF PSYCHIATRY

PERSONAL HISTORY
 DOB: 28 Sep 1997
 Uneventful early childhood
 Took keen interest in Basketball, football, table tennis
 Captained his school basketball team
 h/o use of cannabis for 1st
time in 11th
std as described
 Was expelled from class and penalised for rolling a
‘joint’ in class
 No h/o
 Child abuse
 Sexual exposure

PERSONAL HISTORY
19/11/2016
 Completed 10th std with 9.0 CGPA
 Scored 86.2% in12th
std
 Joined 1st
Yr BSc Economics in Pune in
2015
 Failed 3 subjects in the 2nd
semester
 Occasional use of Alcohol and Tobacco
DEPT OF PSYCHIATRY

PREMORBID HISTORY…
 Cheerful Extrovert
 Numerous male & female friends, was popular
among his classmates and peers
 Keen interest in contact sports
 Thrill seeking behaviors

Importance of evaluating Pre-morbid
Personality?

What is the importance of
evaluating Pre-morbid Personality?
 Certain personality traits predispose to
Psychiatric illnesses
 Histrionic Personality : Dissociative Disorders
 Anti-social Personality : Substance use Disorders
 Personality disorders need treatment in their
own right; may be masked by current/ overt
psycho-pathology

Summary of History ?

Summary of history
19/11/2016
 19yr old 3rd
semester BSc student
 Family h/o BPAD in Maternal uncle
 Pre-morbidly an extrovert
 With h/o regular increasing Cannabis use over 03
yrs
 Had irritable mood, disturbed sleep,
overtalkativeness and delusions of persecution for
last 05 days
DEPT OF PSYCHIATRY

GENERAL EXAMINATION
 Ht- 173cm Wt- 60kg BMI – 20 Kg/m2
 Pulse- 86/min, Regular, Normal volume
 BP- 128/78 mm Hg Right arm supine
 No pallor, icterus, cyanosis, lymphadenopathy,
edema, clubbing
 No digital tremors/moist palms
 No swelling in the front of neck
 No needle-tracks
 No discoloration of teeth/lips/nails/ palms
 No burn marks on fingers

What signs of Substance use should
one look for in Gen Examination?

What signs of Substance use should
one look for in Gen Examination?
19/11/2016
 Hyper-pigmentation of fingers, nails and teeth
 Burns and scars on hands, face
 Puncture marks for i/v drug use
 Skin-popping
 Nasal Septal
atrophy
 Chronic rhinitis
DEPT OF PSYCHIATRY
Benjamin J. Sadock. Chap: Signs & Symptoms in Psychiatry. Kaplan & Sadock’s
CTP 9th
Ed, 2009

SYSTEMIC EXAMINATION
CNS –
 Cranial Nerves – Normal, Fundoscopy- NAD
 Motor system – Normal
 Sensory system – Normal
 Skull and spine - Normal
Abdomen – Soft, non-tender
CVS - S1S2 heard, no abnormal sounds
Respiratory System – Normal Vesicular Breath
Sounds, no abnormal sounds

What signs specific to
Substance use should one
look for in Systemic
Examination?

What signs specific to Substance use should
one look for in Systemic Examination?
 CNS
 Impaired higher mental functions
 Dysarthria
 Cerebellar signs
 CVS
 Signs of Endocarditis in i/v drug
users
 Roth’s spots
 New or changed Cardiac murmurs
 Osler’s Nodes
 Resp
 Signs of COPD in chronic
smokers
 Wheeze
DEPT OF PSYCHIATRY
 Abdomen
 Signs of chronic liver
disease in chronic
alcohol use
 Alopecia
 Gynaecomastia
 Hepatomegaly/Cirrhosi
s
 Spider Naevi
 Palmar erythema
 Testicular Atrophy
19/11/2016

MENTAL STATUS
EXAMINATION
 Appearance and Behaviour :
 Boisterous, irritable
 Un-cooperative initially for interview
 Did not observe social etiquette
 Rapport difficult to establish
 Psychomotor activity increased
 Speech :
 Increased rate, tone and volume
 Irrelevant at times

MENTAL STATUS
EXAMINATION
 Mood :
 “Tension hai”
 Fluctuates during the day
 Affect :
 Anxious, irritable when thwarted
 Increased range and reactivity
 Congruent
 Thought :
 Stream : Normal
 Form : No loosening of association
 Content : Delusion of persecution

What is Mood?
Benjamin J. Sadock. Chap: Signs & Symptoms in Psychiatry. Kaplan & Sadock’s CTP 9th
Ed,
2009 Lippincott W& W. Pg 927.
• Predominant, Pervasive and Sustained
emotional feeling tone that is experienced
internally by the patient

What are grades of elevated mood?

What are grades of elevated mood?
 Euphoria: Exaggerated feeling of well-being
that is inappropriate to apparent
circumstances
 Elation: Affective state of joyous gaiety which
is not in keeping with life
circumstances
 Exaltation: Feeling of elation together with
grandiose identity/ability
 Ecstasy: Feeling of intense rapture or pleasure
Benjamin J. Sadock. Chap: Signs & Symptoms in Psychiatry.
Kaplan & Sadock’s CTP 9th
Ed, 2009 Lippincott W& W. Pg 239.

What is Affect?

What is Affect?
 Affect is the expression of mood, i.e. what
the patient’s mood appears to the clinician
Ed,
2009 Lippincott W& W. Pg 927.

DISORDERS OF THINKING

DISORDERS OF THINKING
 Classification
 Disorders of the stream of thought
 Disorders of the possession of thought
 Disorders of the content of thinking
 Disorders of the form of thinking
Fish psychopathology 3rd
edition, pg 46

STREAM OF THOUGHT
 Disorders of tempo
 Flight of ideas
 Inhibition or retardation of thinking
 Circumstantiality
 Disorders of the continuity of thinking
 Perseveration
 Thought blocking
edition , pg 46

POSSESSION OF THOUGHT

POSSESSION OF THOUGHT
 Thought alienation - patient has the
experience that their thoughts are under
the control of an outside agency or that
others are participating in their thinking
 Thought insertion
 Thought withdrawal
 Thought broadcasting
edition , pg 46

CONTENT OF THINKING
 Delusions
 Overvalued Ideas
edition , pg 46

DISORDERS OF FORM OF
THOUGHT ?
 Transitory thinking - The grammatical and
syntactical structures are both disturbed in
transitory thinking
 Derailment
 Substitution
 Omissions
edition pg 47,48

THOUGHT ?
 Derailment – Thought slides on to a
subsidiary thought
 Substitution – A major thought is
substituted by a subsidiary
one
 Omissions - Intention itself is interrupted
and there is a gapFish psychopathology 3rd
edition pg 47,48

THOUGHT ?
 Drivelling thinking
 Desultory thinking

THOUGHT ?
 Drivelling thinking – the patient has a
preliminary outline of a complicated thought, but
loses preliminary organisation of the thought, so
that all the constituent parts get muddled
 Desultory thinking - speech is grammatically
correct but sudden ideas force their way in from
time to time. continuity is loosened

MENTAL STATUS EXAMINATION
19/11/2016
 Perception : No perceptual abnormality
 Attention : Arousable
 Digit Forward score : 4
 Concentration : ill-sustained
 Distractible; Serial 7 subtraction score: 3
 Orientation
 Time
 Place
 Person
Oriented
DEPT OF PSYCHIATRY

19/11/2016
 Memory
 Immediate -
 Recent
 Remote
 Judgment
 Social
 Test
 Abstract thinking
 Proverb interpretation
 Similarity test
Intact
Impaired
Impaired
DEPT OF PSYCHIATRY
Impaired

19/11/2016
 Insight: Absent 1/5
 Bio-drives
 Sleep : Duration markedly reduced, difficulty
falling asleep
 Appetite : markedly reduced
 Energy : Normal
 Libido : Did not report or exhibit any
increase/decrease in sexual interest/activity
DEPT OF PSYCHIATRY

LEVELS OF INSIGHT

LEVELS OF INSIGHT
 Level 1: Complete denial of illness
 Level 2: Slight awareness of being sick, but
denying it at the same time
 Level 3: Awareness of being sick, but blaming it
on external factors
 Level 4: Intellectual Insight – Admission of
illness, recognition that symptoms are
due to irrational feelings or disturbances
 Level 5: True emotional insight – Emotional
awareness of feelings and meaning of
symptoms, leads to change in future
behaviour
Ed, 2009

INVESTIGATIONS
 Urgent :
 Urine Toxicology Screen
: Positive for Cannabis
 Routine :
 Hb: 12.8 g/dL
 TLC : 6000/cu mm
 DLC: N76L34E2M0
 S. Bil: 0.6 mg/dl
 SGOT/SGPT: 28/34
IU/L
 Blood Urea: 19
mg/dL
 S. Creatinine: 0.8
mg/dl
 HIV: Neg
 HBsAg: Neg
 VDRL: Non-reactor
 Bld Glucose
(R):89mg/dL
 CXR (PA View): NAD
 ECG: WNL
 NCCT Head: NAD

Formulation?

Formulation
19/11/2016
 19 yrs old male with
 Family history of Bipolar Affective disorder in
maternal uncle
 Pre-morbid extrovert
 In the background of regular use of Cannabis over
the past 03 years, achieving craving, tolerance,
loss of control and withdrawal symptoms during
this period
 Presented with irritability, initial insomnia, delusion
of persecution when he attempted complete
abstinence from cannabis 05 days ago
DEPT OF PSYCHIATRY

PROVISIONAL DIAGNOSIS

PROVISIONAL DIAGNOSIS
19/11/2016
 Cannabis Dependence Syndrome
 Cannabis induced Psychotic Disorder
DEPT OF PSYCHIATRY

DIFFERENTIAL DIAGNOSIS

DIFFERENTIAL DIAGNOSIS
19/11/2016
 Schizophrenia
 Bipolar Affective Disorder
DEPT OF PSYCHIATRY

How can we differentiate
between a Substance Induced
and a Primary Psychotic
Disorder?

How to differentiate between a Substance
Induced and a Primary Psychotic Disorder?
19/11/2016
 Temporal association between substance use
and the onset of of psychotic symptoms
 Psychiatric condition prior to the onset of use
of substance
 Course of psychotic symptoms in relation with
the course of substance use
 Amelioration of psychotic symptoms on
cessation of substance use
 Family history suggestive of genetic
predisposition to primary psychotic illness
DEPT OF PSYCHIATRY

What are the medical uses of
Cannabis?

MEDICAL USES OF CANNABIS
19/11/2016
 Glaucoma
 Crohn’s Disease and other chronic inflammatory
illnesses
 Loss of appetite and weight loss in AIDS
 Tourette’s Syndrome
 Multiple Sclerosis
 Intractable epilepsy assoc with MR in children
 Asthma
 Chemotherapy induced nausea in treatment of
Cancer
DEPT OF PSYCHIATRY

Management

MANAGEMENT
19/11/2016
 Psychotherapy (started later)
 Structured milieu
 Warmth, emotional support
 Motivation Enhancement Therapy - (MET) is a
counseling approach that helps individuals
resolve their ambivalence about engaging in
treatment and stopping their drug use. This
approach aims to evoke rapid and
internally motivated change, rather than guide
the patient stepwise through the recovery
process.
 Coping skills training and CBT
DEPT OF PSYCHIATRY

COGNITIVE BEHAVIOURAL
THERAPY
 CBT is a form of psychotherapy that attempts
to modify the interpretations of experiences
that determine feelings and behaviors
 The premise of CBT is that cognition can
influence feelings and behaviors
 CBT interventions help people to identify and
correct thoughts and misinterpretations of
experiences that are at the root of problematic
behavior
Kaplan & Sadock’s CTP 9th
Ed, 2009

AIM OF PRESENTATION
19/11/2016
 Appraise about
 Manifestations of Cannabis withdrawal
 Awareness of features of Cannabis induced
psychosis
 Behavioural and social disruption due to
substance use
 Management approach
DEPT OF PSYCHIATRY

Questions?

Thank you

cannabis poisoning

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