Prolonged hallucinations and dissociative self mutilation following use of Salvia divinorum in a bipolar adolescent girl

Article (PDF Available)inJournal of Substance Use 15(2):113-117 · April 2010with 111 Reads
DOI: 10.3109/14659890903060167
The case of a bipolar 17-year-old girl who developed prolonged vivid hallucinations and a dissociative state involving self-destructive behaviour following the use of Salvia divinorum is presented. The herb has mostly short-term (10–15 min) hallucinogenic properties. Salvatorin A, the main active compound, is a highly selective agonist of the kappa-opioid receptor. The plant is available at tobacco or other specialized stores in many countries such as France, UK, Canada, and USA, where it is legal. The clinical case reported in this article suggests that the recreational use of Salvia divinorum may result in serious psychiatric consequences in vulnerable individuals.
Journal of Substance Use, April 2010; 15(2): 113–117
ISSN 1465-9891 print/ISSN 1475-9942 online © 2010 Informa UK Ltd.
DOI: 10.3109/14659890903060167
TJSU1465-98911475-9942Journal of Substance Use, Vol. 1, No. 1, Aug 2009: pp. 0–0Journal of Substance Use
Prolonged hallucinations and dissociative self
mutilation following use of Salvia divinorum
in a bipolar adolescent girl
Prolonged hallucinations following use of Salvai divinorumJ. J. Breton et al.
1Clinique des Troubles de l’humeur, Hôpital Rivière-des-Prairies, Département de Psychiatrie,
Université de Montréal, Montréal, Québec, Canada, 2Équipe d’addictologie ECIMUD, Paris,
France, and 3Groupe hospitalier Pitié-Salpétrière, Paris, France
The case of a bipolar 17-year-old girl who developed prolonged vivid hallucinations and a dissociative
state involving self-destructive behaviour following the use of Salvia divinorum is presented. The herb
has mostly short-term (10–15 min) hallucinogenic properties. Salvatorin A, the main active
compound, is a highly selective agonist of the kappa-opioid receptor. The plant is available at
tobacco or other specialized stores in many countries such as France, UK, Canada, and USA, where
it is legal. The clinical case reported in this article suggests that the recreational use of Salvia divinorum
may result in serious psychiatric consequences in vulnerable individuals.
Keywords: Adolescents, Salvia divinorum, prolonged hallucinations, dissociative state, bipolarity.
Past history
Marylin was first evaluated in a Child Psychiatry Outpatient department (OPD) at the age
of 9 years for phobias, and disruptive and anxious behaviour triggered by separation from
her mother. Her father was diagnosed as bipolar and her mother was chronically
depressed. Further investigations revealed that her mother was also bipolar with cycles of
depression and mania. Marylin had two brothers older than herself. She was born at 30
weeks gestation and hospitalized several times for asthma. She had one episode of febrile
convulsions. A diagnosis of generalized anxiety disorder was made, and individual psycho-
therapy and parental guidance were recommended. The child missed several appoint-
ments, as her mother was not very supportive of the therapeutic intervention. Both mother
and child discontinued the treatment after 18 months.
Correspondence: J. J. Breton, 7070, Boulevard Perras, Montréal, H1E 1A4, Canada. Tel: (514) 323-7260. Fax: (514) 322-4163.
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114 J. J. Breton et al.
At 14 years of age Marylin was admitted to an adolescent in-patient unit as a result of
her emotional outbursts, increased energy, reduced sleep, irritability, and sadness. A diagnosis
of bipolar disorder type 1, with mixed episodes, was made. Lithium was initiated and her
mood status improved. However, partly as a consequence of the parents’ psychiatric prob-
lems, family relationships remained chaotic and conflictual. At that time, the adolescent
started using cannabis and became over weight. She was emotionally unstable, impulsive,
performed poorly at school, and presented with chronic sleep problems (mostly initial
insomnia). She had difficulty accepting her diagnosis of bipolar disorder and, conse-
quently, took her medication irregularly. She had to be hospitalized three times in the same
year for mixed episodes with visual hallucinations, self-mutilation, and oppositional
behaviour. She was diagnosed with borderline personality disorder, later confirmed with
the Diagnostic Interview for Borderlines—Revised (Zanarini, Gunderson, Frankenburg, &
Chauncey, 1989), in addition to the diagnosis of Bipolar disorder. Clonidine and quetiapine
were added to decrease aggressive behaviours and improve sleep. She was finally referred
to a residential centre for 18 months, but had to be hospitalized twice for suicidal crises
and self-mutilation.
Current episode
At the time of the Salvia divinorum consumption, the patient was 17 years old and living in
a block of flats supervised by an educator, who was resident at the site. Marylin was under-
going a period of symptomatic remission and expected to make good progress. She did not
take cannabis and had not self-mutilated for the past 9 months. She was enrolled in a
university teaching hospital Mood Disorders OPD. Her daily pharmacological treatment
was lithium 900 mg, loxapine 15 mg, clonidine 0.1 mg, fluoxetine 10 mg, and lipitor 10
mg (for elevated cholesterol). On a Sunday night in July, she smoked dried leaves of Salvia
divinorum with two other male adolescents. The dried leaves were bought legally in a store.
The legality and ease of access led the adolescents to believe that the plant was not harmful.
The three adolescents smoked the ‘joint’ of Salvia seated on a bench in a park. The two
boys encountered immediate changes in perception with feelings of derealization (being in
a spatial vessel for one and moving very rapidly for the other), which lasted for 10–15 min.
Marylin was bewildered because she felt no effect of smoking Salvia divinorum. How-
ever, 3 h later, while going to bed, she started to experience feelings of derealization with
frightening visual, auditory, olfactory, and somatic hallucinations. Everything was unreal,
with the floor moving like the surface of water and voices coming out of furniture. She saw
dead people, heard screams and moaning, felt burning smells and the sensation of a puff
on her neck. In the past, the visual hallucinations she experienced occurred only during her
mixed episodes. She became very frightened and called both her mother at home and her
educator at the site. The educator went up to her flat and was able to progressively calm
her down. The hallucinations continued the next day, and worsened over the afternoon
and the evening. She went to bed with her eyes still open (unable to sleep) and had what
she later described as a 45-min ‘blackout’. Upon arousal she saw blood on the sheets,
discovered several cuts on her left forearm and abdomen, and realized with anguish that
she had been self-mutilating during this episode. She had absolutely no recollection of her
behaviour. She panicked and called her educator and the emergency services of two hospitals
to get help. Her educator came up and was again able to calm her down. The emergency
calls were cancelled. The frightening hallucinations decreased slowly and she was able to
sleep. The next morning, she got in touch with our Mood Disorders Clinic and had an
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Prolonged hallucinations following use of Salvia divinorum 115
appointment with the child psychiatrist (JJB) and the nurse (SR) the following day. At the
mental examination, she was very anxious, but not psychotic. She reported suicidal urges
when near a metro station. Loxapine was increased, and a follow-up meeting with Marylin
and her educator was planned the following day. The hallucinations and the suicidal urges
decreased progressively over the following 4 days. She recovered completely after 1 week
from her episode and returned to her previous adequate level of functioning.
Salvia divinorum
Description. Salvia divinorum is a plant in the sage genus belonging to the mint family. The
Sage genus encompasses 700 species. The herb was originally cultivated in the state of
Oaxaca, Mexico by Mazatec Indians, and used for spiritual and religious purposes as a
substitute for psilocybes, when these mushrooms were not available. The herb has mostly
hallucinogenic properties. In traditional societies, the plant is often a reincarnation of Mary,
who appears and speaks to the user. Other names include ‘Mary herb’, ‘Magic Mint’ and
‘Diviner’s Sage’. The plant can be chewed, drunk (as a juice) or smoked (Hostettmann,
2002). Smoking is the preferred method of use (Dalgarno, 2007). It is known as a very
short-acting drug with psychedelic effects starting immediately after inhalation and lasting
for 5–15 min and not exceeding 2 h. In addition to hallucinations, the drug generates eupho-
ria, identity disturbance, derealization and dissociative phenomena (Dalgarno, 2007;
Gonzales, Riba, Bouso, Gomez-Jarabo, & Barbanoj, 2006; Nortier, 2007).
The plant is available on many web sites and is also available through tobacco or other
specialized stores in countries where it is legal. The drug is presented as a safe, legal, and
undetectable product by usual routine tests, characteristics that make it very appealing for
use by both adults and adolescents. Indeed, web sites devoted to drugs are proliferating
with a large number of commercial sites ignoring the risks and harms related to the use of
psychedelic drugs (Montagne, 2008). A 2005 survey in France revealed that hallucinogens
were used over lifetime by 5.2% of boys and 2.1% of girls 17 years [Observatoire français
des drogues et toxicomanies (OFDT), 2007] and in Quebec, 9% of 12–17-year-old adoles-
cents in secondary schools reported having used hallucinogenic drugs in 2006 (Dubé &
Fournier, 2006). The drug is legal in many countries like France, UK, Canada, and USA,
although not in all states, but prohibited in Spain, Australia, Italy, Sweden, and Denmark.
A recent survey among 1526 college students in the United States revealed that 4.4% of
the sample reported using Salvia over the previous year. Being male, white, member of a
fraternity/sorority group, a heavy alcohol- and drug-user were associated with increased
probability of Salvia use. Alcohol and drug use represented the highest risk factor for tak-
ing Salvia (OR of 11) (Lange, Reed, Ketchie Croff, & Clapp, 2008).
Mechanisms of action. Salvia divinorum is a hallucinogen with specific properties different
from indolealkylamines and phenylalkylamines, the two major classes of hallucinogens
(Nortier, 2007; Stahl, 2008). Indolealkylamines encompass psilocybin and psilocin, the
active compounds of psilocype mushrooms, dimethyltryptamine (DMT) coming from
virola’s bark, ibogaine from Tabernanthe iboga, as well as the classic synthetic hallucinogen
LSD. They act mainly as agonists at 5-HT2A receptor sites with additional effects on other
neurotransmitter systems. The second class is represented by phenylalkylamines encom-
passing mescalin, the active compound of cactus peyote and synthetic drugs, such as the
well known MDMA or ecstasy. They have complex interactions at norepinephrine and
dopamine receptor sites (OFDT data base; Stahl, 2008).
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116 J. J. Breton et al.
Salvatorin A is the main active compound of Salvia divinorum. Salvatorin A does not
have binding affinity for 5-HT2A receptor compared with many hallucinogens. This
compound is a highly selective agonist of the kappa-opioid receptor (Babu, McCurdy &
Boyer, 2008; see Table I). A gender effect difference in elimination was observed in the
only study using intravenous administration on two male and two female rhesus monkeys
with males having a shorter elimination half-life than females. The sedative effect lasted
about 15 min (Grundmann, Phipps, Zadezensky, & Butterweck, 2007).
The case of Marylin is very unusual because of the delay in the psychedelic effects and the
week-long duration of the vivid hallucinatory phenomena. Moreover, this adolescent
presented a dissociative state with self-injury behaviour the day after taking the substance.
The suicidal urges reported during her first visit at our Mood Disorders Clinic appear to be
secondary to the psychological distress. The two other male adolescents had a very short
hallucinatory experience, but the gender effect observed in a non-human primate study
cannot obviously account for such a substantial difference in reactions.
We did not find in the literature any other case describing effects lasting for several days
following the use of Salvia divinorum. The bipolarity of this patient with previous episodes
of visual hallucinations, self-mutilation, and suicidal crises made her more vulnerable. In
addition, the psychotropic medication taken by Marylin, with molecules having affinity for
alpha adrenergic, dopamine, and 5-HT receptors, might have contributed to the intense
and prolonged reaction in this bipolar girl, although the molecular mechanisms involved in
neurotransmitter systems are quite difficult to elucidate. Hallucinogens act at serotonine
and dopamine systems on reward circuits consisting of the ventral tegmental area, the
nucleus acumbens, and the amygdala (Stahl, 2008). A neurochemical adaptation of the
dopamine system and its receptors related to the chronic use of the psychotropic medication,
especially loxapine, might have contributed to the delayed and prolonged hallucinatory
phenomena. Use of psychotropic medication as such by adolescents with mental disorders
could then be a major risk factor for serious complications following use of hallucinogens.
n c
cs o
c compoun
s use
or recreat
Active compounds Mechanism
Mushroom Psylocybe (Psilocybe cubensis,
hoogshagenii, mexicana, muliercula,
Psilocybin, Psilocin
Agonist R 5HT-2
Interaction with 5HT network
Mushroom Panaeolus
Mushroom Gynopilus Boletus manicus
Morning glory (Ipomea) Amide of d-lysergic acid Interaction with 5HT network
Ololuiqui (Rivea corymbosa) Agonist R 5HT-2
Virola (Virola calophylla) Indolealkylamins Inhibition of mono-amine oxydase
Agonist R 5HT1 and R-5HT2
Iboga (Tabernanthe iboga) Indolealkylamins Agonist of g and k-opioid R
Ibogaine Antagonist R NMDA
Cactus peyote Mescalin Agonist dopamine R,
(Iophophora Williamsi) Agonist noradrenaline
Cactus San Pedro
Scarlet sage (Saslvia divinorum) Salvinorin A Agonist of k-opioid R
Based on OFDT data (Observatoire français des drogues et toxicomanies).
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Prolonged hallucinations following use of Salvia divinorum 117
Overall, it appears clear that the recreational use of Salvia divinorum can result in serious
psychiatric problems in vulnerable individuals. In addition to prolonged hallucinatory
phenomena, a dissociative state involving self-destructive behaviour (self-mutilation in this
case) following use of the drug can have harmful consequences. Discussion about the legal
status of the drug in many countries should take into consideration descriptions and
comments, such as the one presented in this clinical case-study.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the
content and writing of the paper.
Babu, K. T., McCurdy, C..R., & Boyer, E..W. (2008). Opioid receptors and legal highs: Salvia divinorum and
Kratom. Clinical Toxicology, 46, 146–152.
Dalgarno, P. (2007). Subjective effects of Salvia divinorum. Journal of Psychoactive Drugs, 39, 143–149.
Dubé, G., & Fournier, C. (2006). Enquête québécoise sur le tabac, l’alcool, la drogue et le jeu chez les élèves du
secondaire, 2006. Institut de la statistique du Québec, Publications du Québec.
Gonzales, D., Riba, J., Bouso, J..C., Gomez-Jarabo, & Barbanoj, M. J. (2006). Pattern of use of Salvia divinorum
among recreational users. Drug and Alcohol Dependence, 85, 157–162.
Grundmann, O., Phipps, S. M., Zadezensky, I., & Butterweck, V. (2007). Salvia divinorum and salvitorin A: An
update on pharmacology and analytical methodology. Planta Med, 73, 1039–1046.
Hostettmann, K. (2002). Les plantes qui deviennnent des drogues, Éditions Favre.
Lange, J. E., Reed, M. B., Ketchie Croff, J. M., & Clapp, J. D. (2008). College students’ use of Salvia divinorum.
Drug and Alcohol Dependence, 94, 263–266.
Montagne, M. (2008). Drugs on the Internet. 1: Introduction and web sites on psychedelic drugs. Substance Use
and Misuse, 43: 17–25.
Nortier, E. (2007). Drogues anciennes, drogues nouvelles, pratiques actuelles (2ième partie), Psychiatric Science
and Human Neuroscience, 5, 71–88.
Observatoire français des drogues et toxicomanies (2007). Hallucinogènes: une consommation limitée mais plus
présente chez les adolescents et les jeunes adultes. Synthèse OFDT, March 2007. Available at:
Stahl, S. (2008). Stahl’s essential psychopharmacology. Neuroscientific basis and practical applications, 3rd edn.
Cambridge: Cambridge University Press.
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