‍Clinical Lessons Learned About Cannabis Over the Past Thirty–Five Years: Starting with James – Dale Mortimer, M.D.

‍Clinical Lessons Learned About Cannabis Over the Past Thirty–Five Years – Starting with James‍

In order to better appreciate Dr. Mortimer's clinical anecdote below, here is some clinical background information (– Dr. Mortimer has borrowed liberally from the discussion of cube–copying in The Mental Status Examination in Neurology, Fourth Edition – Richard L. Strub and F. William Black, 2000).

Constructional ability (also known to as constructional praxis or visuoconstructive ability) is the ability to draw or construct two–dimensional or three–dimensional figures or shapes. Asking a patient to copy a two–dimensional cube on to a sheet of paper can more completely assess the patient’s overall brain functioning. Cube copying assesses the patient’s ability to perform a very complex perceptual–motor ability task involving the integration of occipital, parietal, and frontal lobe functions of the brain. The relations of the cube’s angles and sides, the integration of parts of the cube into a whole pattern, orientation of the cube on the page, and three–dimensionality must all be appreciated by the patient for accurate motor integration to occur. Copying a drawn cube should be easily and accurately copied in non–retarded individuals over the age of 12 years old. Those patients who produce distorted cubes warrant a more thorough evaluation to assess for the the possibility of such underlying medical/neurological disorders as a tumor, stroke, dementia, cerebral atrophy, a toxic metabolic disturbance, or parietal lobe lesions – this is what neurologists collectively referred to as “organic brain diseases.”

In 1986, during my psychiatry residency training at the Vancouver campus of the Veterans Administration Medical Center, my psychiatric supervisor asked me to evaluate James. At that time, James was a 30–ish year old, single, unemployed, black, non–combat veteran who, while on active military service, was diagnosed with chronic paranoid schizophrenia. After reviewing James’ medical records, I learned that James experienced his first “psychotic break” in his early 20s while in the Army. James was then diagnosed with chronic paranoid schizophrenia, honorably discharged, deemed 100% psychiatrically disabled, and awarded disability income of about $2,000 monthly at that time. James had been seen every three months at the VAMC psychiatric clinic for psychiatric re–assessment which included checking how he was doing on his anti–psychotic medications (i.e., haloperidol).

On the day that I met James, he was a young–appearing, trim, smiling, superficially cooperative black man who was masterfully evasive in responding to nearly all of my questions. Since I did not have access to any “collateral informants” who could then give me a more complete picture of James’ current level of daily functioning, I did the best I could to assess his response to antipsychotic medications with the information that I had. I learned that James’ day was completely unstructured, and he was completely unmotivated: he didn’t exercise, watch TV, listen to music, attend any structured social or academic activities, have any hobbies, or read for pleasure. James never married, didn’t have a current girlfriend (or boyfriend), and said that he wasn’t particularly interested in sex. James didn’t have any close friends. James didn’t stay in contact with his parents or siblings. James didn’t care about current events. James was artfully vague in describing to me how well he did as a student in high school, and he said didn’t recall was his GPA was when he graduated from high school. While he knew the current US President, the current date, the year, the day of the week, and the time of day we were chatting, James could not interpret simple proverbs I recited to him (e.g., Rome wasn’t built in a day; Don’t cry over spilt milk); James couldn’t identify commonalities between two related items (e.g., apple and banana; happy and sad; a tree and a fly); and James denied having any current psychotic symptoms (e.g., hearing voices that no one else heard; believing that the TV was commenting on his behavior; thinking that others unknown wanted to harm him, etc.). And James denied any side–effect from taking his anti–psychotic medication. It sounded to me as though all James did throughout the day was smoke cigarettes! I concluded that James’ profound lack of motivation, his social withdrawal, his nearly content–free speech, and his concrete thinking (i.e., he wasn’t able to abstract) were consistent with his diagnosis of chronic paranoid schizophrenia. It appeared that James’ current antipsychotic medication was effective in preventing any recurring psychotic episodes, and that the medication was well–tolerated. But I it was obvious to me that there was still plenty of “room for improvement” in James’ current quality of life.

I was nearing the end of James’ psychiatric examination when he abruptly interrupted me, explaining that he was having a “nicotine fit,” and needed “a quick cigarette break.” I consented to the interruption, with the proviso that he “hurry back.” And I waited for James. And waited…Still no James. I walked around the VA facility, looking for James. I finally found a VA staff person who knew where veterans were permitted to smoke. Arriving at the VA outdoor smoking court yard, there I saw James, reclining in a lounge chair, enjoying the sunshine, and smoking what appeared to me to be a very thick, hand–rolled cigarette.

I briskly walked up to James and said: “James, I finally found you! We are both very busy, so if you will just copy this cube for me, we can then say our good–byes.” I then gave James my clipboard with a cube I sketched on the paper.

James then first protested non–verbally, turning away from me, and then said: “Man, I don’t want to copy no damn cube.”

But I was persistent: “James, just copy the damn cube so we can then say our good–byes.” James again tried to “shoo” me away, but I was refused to leave. James finally relented.

Below are the reduced tracings of my hand–drawn cube (on the upper left), and James’ two earnest attempts to “just copy the damn cube as accurately as you can” (on the right side). During his task, it appeared to me that James was trying as well as he could to copy my cube, and from the expression on his face, James himself realized that he was failing miserably at accurately copying the “damn cube.” Below is a reduced tracing of both my cube (upper left), and James’ two sincere attempts to copy my cube (on the right and below).

After seeing James’ drawing, I had an epiphany: it wasn’t cigarettes that James smoked throughout the day; and James’ diagnosis was not chronic paranoid schizophrenia! Being too outraged to formulate a clever reply, I could only exclaim indignantly: “James, what are you smoking!”

James then laughed and said with a smile: “This is my therapy, man.” James took another drag on his marijuana joint, turned away from me, and resumed his conversation with another young black veteran sitting to his right. James had given his best effort to “copy the damn cube.” And I had to honor our agreement: our interview was over.

Back at my VA office, as I dutifully wrote down my psychiatric assessment of James as my supervisor had requested, I realized that James’ “psychotic break” as a young man was a combination of the stresses of transitioning from civilian to military life, plus the cognitively impairing effects of smoking a lot of cannabis. James wasn’t truly psychotic and his diagnosis was certainly not chronic paranoid schizophrenia. I was convinced that James never took any of his anti–psychotic medication which had been prescribed for him. James was constantly “baked!” James’ profound lack of motivation, social withdrawal, his nearly contentless–speech, his impaired ability to abstract, and his distorted cube copying were, most likely, all the result of his chronic, daily cannabis use!

And James was a good teacher. Since our meeting in 1986, I have routinely incorporated cube–copying into my initial psychiatric evaluation of patients over the age of 12 years old, and I now have a large three–ringed binder filled with copies of the…um… “cubes” that my cannabis–smoking (and, more recently, cannabis–dabbing and cannabis–munching) patients have drawn for me. On these pages, I also record their age, their frequency of cannabis use, the date of their last cannabis use – and whether the patient is using other substances (e.g., most often, alcohol) or medications and relevant medical history.

Based on my extensive clinical experience, here is what I have concluded. First, here is the bad news. The lingering effects of cannabis use can continue to interfere with: thinking clarity, motivation, the ability to abstract (e.g., and see how his or her behavior is contributing to his or her current interpersonal difficulties), restorative sleep, mood, and processing speed for at least a week after last cannabis use. Furthermore, regular cannabis use interferes with the benefits which would otherwise be derived from any psychiatric medications, by the way. Lastly, based on my extensive clinical sample, I have concluded that the subtle but clearly identifiable compromised brain functioning continues for up to six months after last cannabis use. Now for the good news. If my cannabis–using patients can abstain from all cannabis (and, of course, all alcohol), then their brain functioning (and any substance–induced psychiatric and general medical symptoms associated with the substance use) almost always returns to their expected normal functioning, with resolution in disturbed sleep, unstable mood, marked improvement in processing speed, and ability to abstract (i.e., they are able to accurately see how their own behavior contributes to their recurring interpersonal difficulties).

What did I learn from James that day over thirty–five years ago?

1. Those individuals who are under the acute effects of cannabis can appear to be experiencing either a dementing process, another organic brain disease, or chronic paranoid schizophrenia; and
2. Cube–copying can help identify cannabis–induced brain impairment.

After Dr. Mortimer earned his medical degree from Oregon Health Sciences University, Dr. Mortimer continued at OHSU to first complete general adult psychiatry training (– during which time, Dr. Mortimer met James as above), and then a two–year child & adolescent psychiatry fellowship training program. Dr. Mortimer is, thus, not only a fully trained general adult psychiatrist, but Dr. Mortimer is also a fully–trained child & adolescent psychiatrist. Since first meeting James, Dr. Mortimer has served as a psychiatric consultant to at least five community–based, long–term residential, and hospital–based chemical dependence treatment programs. Among Dr. Mortimer’s professional medical accomplishments, Dr. Mortimer is a diplomate of (– that is, he has a diploma in general adult psychiatry from) the American Board of Psychiatry and Neurology (i.e., Dr. Mortimer is “Board Certified in Psychiatry”). Dr. Mortimer has also been on the clinical teaching faculty for Oregon Health Science University’s Department of Psychiatry, and for the Family Practice Training Program at Eastmoreland Osteopathic Hospital in Milwaukie, Oregon. Dr. Mortimer has served as both a principle investigator and as a clinical investigator for phase III clinical drug trials. Over the past 31+ years, Dr. Mortimer has enjoyed seeing some of his many clinical writings published in peer–reviewed international medical journals. Dr. Mortimer is currently licensed to practice medicine in the State of Washington, maintaining a full–time, solo private practice in child, adolescent, and general adult psychiatry in the non–incorporated Hazel Dell neighborhood of Vancouver, Washington. Also of perhaps some interest: Dr. Mortimer currently enjoys the distinction of having the longest–surviving, private practice in child & adolescent psychiatry in the county.