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Catha (Khat plant)
Biological name (genus and species):
Parts used for medicinal purposes:
Chemicals this herb contains:
Cathine (a form of ephedrine)
Stimulates brain and spinal cord through synapses.
Interferes with absorption of iron and other minerals when
Miscellaneous information:Can be habit forming. Addicts become talkative then depressed
UNPROVED SPECULATED BENEFITS
Leaves chewed or steeped to make tea to treat fatigue.
WARNINGS AND PRECAUTIONS
Don't take if you:Are pregnant, think you may be pregnant or plan pregnancy in
the near future.
Have heart trouble.
Have high blood pressure.
Consult your doctor if you:Take this herb for any medical problem that doesn't improve in
2 weeks. There may be safer, more-effective treatments.
Take any medicinal drugs or herbs including aspirin, laxatives,
cold and cough remedies, antacids, vitamins, minerals, amino
acids, supplements, other prescription or non-prescription
Pregnancy:Dangers outweigh any possible benefits. Don't use.
Breast-feeding:Dangers outweigh any possible benefits. Don't use.
Keep cool and dry, but don't freeze. Store safely away from
Safe dosage:At present no "safe" dosage has been established.
Rated slightly dangerous, particularly in children, persons over For symptoms of toxicity: See Adverse Reactions, Side
Effects or Overdose Symptoms section below.
55 and those who take larger than appropriate quantities for
extended periods of time.
ADVERSE REACTIONS, SIDE EFFECTS OR OVERDOSE SYMPTOMS
|Signs and symptoms:
||What to do:
||Seek emergency treatment.
||Discontinue. Call doctor when
||Discontinue. Call doctor when
|Increased blood pressure
||Discontinue. Call doctor
|Increased heart rate
||Seek emergency treatment.
||Seek emergency treatment.
|Stomach irritation, with
||Discontinue. Call doctor
From the Complete Guide to Vitamins, Minerals & Supplements by H. Winter Griffith, M.D.
© 1988 by Fisher Books; electronic rights by Medical Data Exchange
Everything about Qat/khat/kat
Because khat contains ephedrinelike compounds it seems best included
in this section [a setion on Amphetamines]. Lewin (1931) gave a brief
account of khat and how it was used. Apparently it was taken socially
to produce excitation, banish sleep, and promote communication. It was
used as a stimulant to dispel feelings of hunger and fatigue.
The natives chewed young buds and fresh leaves of catha edulis
(_Celastrus edulis_). This is a large shrub which can grow to tree
size. It originated in Ethiopia and spread until its use covered Kenya,
Nyasaland [now Malawi], Uganda, Tanganyika [now Tanzania], Arabia, the
Congo, Rhodesia [now Zimbabwe and Zambia], and South Africa. The khat
trees are grown interspersed between coffee trees.
Khat was used in Yemen even before coffee and it was immensely
popular. Lewin described khat markets to which khat was brought in
bundles of branches from the mountains.
Khat contains cathine (d-norisoephedrine), cathidine, and cathinine.
Cathine is also one of the alkaloids found in _Ephedra vulgaris_. It is
fortunate, perhaps, that khat is also very rich in ascorbic acid which
is an excellent antidote to amphetamine-type compounds.
In animals, khat produces excitation and increased motor activity. In
humans, it is a stimulant producing a feeling of exaltation, a feeling of
being liberated from space and time. It may produce extreme loquacity,
inane laughing, and eventually semicoma. It may also be an euphorient
and used chronically can lead to a form of delirium tremens. Galkin
and Mironychev (1964) reported that up to 80% of the adult population
of Yemen use khat. Upon first chewing khat, the initial effects were
unpleasant and included dizziness, lassitude, tachycardia, and sometimes
epigastric pain. Gradually more pleasant feelings replaced these
inaugural symptoms. The subjects had feelings of bliss, clarity of
thought, and became euphoric and overly energetic. Sometimes khat
produced depression, sleepiness, and then deep sleep. The chronic user
tended to be euphoric continually. In rare cases the subjects became
aggressive and overexcited. Galkin and his colleague observed 51
subjects who had taken khat. Of these, 27 became excited, 18 became
somnolent, and 6 remained unchanged. The respiratory rate and pulse
rate were accelerated and the blood pressure tended to rise. The
subjects also had a decrease in the functional capacity of the
Lewin, L. (1931) "Phantastica, Narcotic and Stimulating Drugs."
(Translation of 1924, German edition.) Routledge and Kegan Paul, London
AUTHOR Weir, Shelagh.
TITLE Qat in Yemen : consumption and social change
London : Published for the Trustees of the British Museum by British Museum
CALL NO. HV 5822 Q3 W34x 1985
WHAT IS KHAT?
Khat(pronounced "cot") is a natural stimulant from the Catha Edulis
plant, found in the flowering evergreen tree or large shrub which grows
in East Africa and Southern Arabia. It reaches heights from 10 feet to 20
feet and its scrawny leaves resemble withered basil.
Fresh Khat leaves are crimson-brown and glossy but become yellow-
green and leathery as they age. They also emit a strong smell. The most
favored part of the leaves are the young shoots near the top of the plant.
However, leaves and stems at the middle and lower sections are also used.
Khat leaves contain psychoactive ingrediants known as cathinone,
which is structurally and chemically similar to d-amphetamine, and
cathine, a milder form of cathinone. Fresh leaves contain both ingrediants
; those left unrefrigerated beyond 48 hours would contain only cathine,
which explains users' preference for fresh leaves. Other names by which
is known include: Qat, Kat, Chat, Kus-es-Salahin, Mirra, Tohai, Tschat,
Catha, Quat, Abyssinian Tea, African Tea, and African Salad.
EFFECTS OF KHAT AND MODE OF INGESTION
Fresh Khat leaves, which are typically chewed like tobacco, produce
a mild cocaine- or amphetamine-like euphoria that is much less potent than
either substance with no reports of a rush sensation or paranoia indicated.
By filling the mouth to capacity with fresh leaves the userr then chews
intermittenly to release the active components. Chewing Khat leaves
produces a strong aroma and generates intense thirst. Casual users claim
Khat lifts spirits, sharpens thinking, and, when its effects wear off,
generates mild lapses of depression similar to those observed among
Since there appears to be an absence of physical tolerance,
due in part to limitations in how much can be ingested by chewing, there
no reports of physical symptons accompanying withdrawal.
Advocates of Khat use claim that it eases symptoms of diabetes,
asthma, and stomach/intestinal tract disorders, Opponents claim that Khat
damages health, suppresses appetite, and prevents sleep.
TRADITIONAL USERS OF KHAT
Khat has been used since antiquity as a recreational and religious
drug by natives of Eastern Africa, the Arabian Peninsula, and throughout
the Middle East. In the US, Khat use is most popular among immigrants
from Yemen and the East African nations of Somalia and Ethiopia.
Traditionally, in those societies that have not evolved cultural
or support systems to integrate Khat use into the social fabric, the
decreased productivity and diversion of income attributed to its use in
a socio-historical context, use is an accepted practice, occuring in
environments that give positive reinforcement and meaning to the
PACKAGING AND AVAILABILITY
Khat is usually packaged in plastic bags or wrapped in banana
leaves to retain its moistness and freshness. It is often sprinkled
with water during transport to keep the leaves moist. Khat also may be
sold as dried or crushed leaves or in powdered form.
Khat iis becoming increasingly available in the US, especially in
cities like NY, DC, LA, Boston, Dallas, and Detroit. It is commonly sold
in resteraunts, bars, grocery stores, and smoke shops that cater to East
Africans and Yemins--after its importation from Kenya, Egypt, and Arabia.
Because Khat in leaf form starts to lose its potency after 48 hours, it is
generally shipped to the US on Thursdays, Fridays, and Saturdays for
CURRENT LEGAL STATUS
Until very recently, Khat was classified as a schedule IV substance
by the DEA. Cathinone, an ingrediant present only in fresh-picked leaves,
(within 48 hours of harvest) has now been classified as a schedule I
the most restrictive category used by the DEA. Cathine, an ingrediant that
remains in Khat after 48 hours, is still classified as a schedule IV
(one that has low potentail for abuse and has a current accepted usage in
treatment). Law enforcement efforts directed against Khat in the US have
minimal thus far.
There is some doubt as to whether khat will become a popular street
drug in this country like crack and other drugs. However, illegal labs
have been discoverred using a synthetic form or Khat's most active
(cathinione) which is called "Methcathinone", known on the street as "Cat".
From the perspective of street users, Khat is not considerd to be a
"street drug" with a desirability comparable to heroin, cocaine, crack,
marijuana, or pills.
Media attention given to Khat is probably bringing about an
in its use, and street adddicts have been observed by the OASAS Street
Studies Unit seeking to purchase Khat. Howeverr, street addicts and other
non-African/Arab seekers of khat are being turned away by sellers.
inquiries by field staff of African/Arab sellers of Khat indicate they are
not selling it as a "drug" and therefore do not seek outsiders who would
bring additional attention to them.
Researchers have not observed street sales of Khat. However, a
member of the Street Studies Unit was told by an Arab Teenaager, standing
in close proximity to an Arab resteraunt, that he was waiting to buy a
bundle of Khat for $28 when the shipment arrived "after five." Street
researchers have been informed that Khat is being sold for $300-$400 a
with a bundle of leaves selling for $28-$50.
From the standpoint of their cultural norms, the African/Arab
and users observed by the OASAS Street Studies Unit do not consider Khat to
be illegal and often oppenly advertise its availability on signs in
resteraunts and grocery stores much as they would any other food product.
TREATMENT FOR KHAT DEPENDENCE
Khat is a sympathomimetic and its pharmacological effects are
to parallel those of amphetimine. Psychiatric manifestations induced by
are similar to the effects of other known stimulants.
Giannini Miller, and Turner (1992) described a recent, successful
attempt to treat 2 cases of Khat dependency using prrotocols similar to
developed for cocaine. Both patients presented for treatment with
manifestations and were screened for stimulant and depressant drug
since substances other than Khat were involved in each case. Specific
procedures for treatment entailed an inpatient detox phase of 1-2 weeks
followed by long-term attendance at outpatient recovery programs.
inpatient detox was facilitated with the use of bromocriptine (ranging in
dose from 0.625 mg. gid in one case to 1.25 mg. gid in the second case, and
tapered off over a period of 5-12 days.) Continued craving for stimulants
one patient resulted in the use of desipramine (200 mg. a day) for up to 6
months post-detox with dose levels gradually tapered downward.
Previous attempts to treat Khat-induced psychosis have employed
thioridazine (300 mg. a day) foor 1 week without reccurrence symptoms.
The Above "STREET ADVISORY" was published 2/93 by OASAS
I have noticed an increase in use of Khat in the upstate NY area
This is probably due to the return of the drug from Somalia. Military
personal that have returned to the Fort Drum and Surrounding areas were
introduced to Khat and seek to continue the use of it.
Subject: Everything you ever wanted to know about Qat
Copyright 1989 Cambridge University Press
Reprinted by permission from
Psychological Medicine, v19: 657-668
Use and abuse of khat (Catha edulis): a review of the distribution,
pharmacology, side effects and a description of psychosis attributed to khat chewing
Charles G. Hindler
and John C. Taylor
There have been relatively few reported cases of psychosis due to khat usage despite its heavy
consumption in certain East African and Arabian countries. Four cases have been reported in the UK.
We report here on three further cases of psychotic reactions to this substance in Somalian males, and
emphasize the need to be aware of khat as a potential substance of abuse, with both medical and
psychiatric complications. The features of khat psychoses are described and the relationship to
amphetamine and ephedrine psychoses is discussed. The forensic aspects of two of the cases which
involved homicide and combined homicide and suicide are highlighted, as is the possible role of social
dislocation from the culture of origin.
Khat (Catha edulis Forsk., Celastraceae family) is an evergreen tree which grows at high altitudes
extending from East to Southern Africa, as well as Afghanistan, Yemen and Madagascar (Krikorian,
1984; Kennedy, 1987). The earliest scientific report concerning khat was in the eighteenth century by
the botanist Peter Forskal (Baasher, 1980).
The chewing of khat leaves is common in certain countries of East Africa and the Arabian peninsula. It
is known by various names, for example 'miraa', and has many spellings (Margetts, 1967; Baasher,
1980; Elmi, 1983a). Historically, khat has been used for medicinal purposes (Kennedy et al. 1983) as
well as an aphrodisiac (Margetts, 1967; Krikorian, 1984), though it was also used for recreational
purposes (Kennedy, 1987). It is most valued for its stimulant effects (Baasher, 1980). Though chewing
is the commonest mode of administration it has been taken as a tea and is occasionally smoked
(Hodgkinson, 1962; Kennedy, 1987). Khat must be chewed while it is fresh, and is usually wrapped in
banana leaves immediately after picking, to preserve its potency (Elm), 1983 a).
The chewing of khat has a deep-rooted social and cultural tradition (Kalix & Braenden, 1985). It is
usually chewed in company (Elm), 1983a, b; Kennedy, 1987), but may be used by individuals to
enhance their working capacity (Elmi, 1983 b; Kalix & Braenden, 1985; Kennedy, 1987). The
principal features of the 'khat experience' are described as increased levels of alertness, ability to
concentrate, confidence, friendliness, contentment and flow of ideas (Kennedy, 1987).
DISTRIBUTION OF USE
Several million people are estimated to be frequent users of khat (Kalix & Braenden, 1985) and its
consumption is increasing (Kennedy, 1987). The prevalence varies widely between the various
khat using countries (Mancioli & Parrinello, 1967; Omolo & Dhadphale, 1987a). In Somalia, Elmi
(1983a,b) estimates that about 18 % in the South and 55 % of the population in the North are
consumers. The 'khat party', which is described in detail by Baasher (1980) and others (Kennedy et al.
1983; Kalix, 1984a; Weir, 1985; Giannini et al. 1986; Kennedy, 1987) is a predominantly male
pastime, though women are occasionally involved (Elm), 1983 a; Luqman & Danowski, 1976).
Kennedy (1987) estimates that approximately 50 60 % of women chew khat more than once a
a week compared with 80-85% of men. In countries such as Yemen and Somalia many houses have a
room specifically used for chewing khat (Basher, 1980).
East Africa, South West Arabia and Madagascar are the areas of major production and consumption.
Recently, the use of khat in Yemen has been reviewed by Mckee (1987). While Muslims are the most
avid chewers (Krikorian, 1984), many Christians and Yemenite Jews in Israel use khat (Kalix, 1987).
In the past, more than one country has prohibited or restricted its use (Al-Thani, 1983; Kennedy, 1987;
Kalix, 1987), although today khat circulates freely in all the above countries (Elmi, 1983a). In Yemen,
khat is regarded as beneficial, though it was considered desirable to prevent the younger generation
developing the habit (Mckee, 1987). Such ambivalent attitudes have made it difficult to formulate a
coherent policy for coping with the problems of khat consumption. Newspaper reports suggest that
khat has only recently been introduced into the UK (Hogg & Rogers, 1985; Busby, 1987). Its use is
largely confined to those ethnic communities accustomed to its use (Gough & Cookson, 1987),
particularly in East London, the Somali community in Liverpool (Gough &Cookson, 1984, 1987) and
the Yemeni community in South Wales (Mayberry et al. 1984). There are, presently, no legal
restrictions to its sale.
The Pharmacology and Pharmacokinetics of Khat
The alkaloid fraction is the active constituent of khat and cathine (d-norpseudoephedrine) was initially
isolated (WHO Advisory Group, 1980). The search for a more powerful stimulant (Halbach, 1972)
led to the isolation of a new alkaloid (a-aminopropiophenone) from the fresh leaf (Braeden, 1979;
Szendrie, 1980), designated cathinone (UN Document, 1975) which has the same basic configuration
as amphetamine (Schorno &Steinegger 1979). Other constituents include tannins, amino-acid and a
significant amount of ascorbic acid, magnesium and beta-carotene (Kalix, 1984a; Kalix & Braeden,
1985; Kennedy, 1987). The market value of the leaves correlates with the cathinone contents (Kalix &
Little is known about the pharmacokinetics of cathinone. It is rapidly absorbed after oral administration
(WHO, 1985) and is metabolized in the liver with only a small fraction appearing in the urine (Kalix &
Braenden, 1985). The more rapid and intense action of cathinone compared with cathine, is explained
by its higher lipid solubility, facilitating access into the central nervous system (Zelger et al. 1980). In
animal studies, cathinone has positive inotropic and chronotropic effects on the heart, a pressor effect
on arteries, increased blood pressure and constriction of the vas deferens (Kalix & Braenden, 1985;
Knoll, 1979) as well as producing excitation and increased activity (WHO, 1980; Kalix & Braenden,
1985). It increases metabolic rate and oxygen consumption, causes hyperthermia and has an analgesic
effect via activation of monoaminergic pathways mediating conception (Yanagita, 1979; WHO, 1980;
Ahmed et al. 1983; Nencini et al. 1984b, c; Kalix & Braenden, 1985). Cross-tolerance has been
demonstrated between d-amphetamine and d-cathinone (Schuster & Johanson, 1979), and both have
similar stimulant effects (Rosecrans et al. 1979) with a self-administration pattern resembling cocaine
(Yanagita, 1979). At the cellular level cathinone has a similar effect to amphetamine at central
dopaminergic synapses (Kalix, 1983a,b; Kalix & Braenden, 1985), as well as effects on other central
and peripheral neurotransmitters (Knoll, 1979; Nencini et al. 1984c; Kalix & Braenden, 1985).
THE EFFECTS OF KHAT
El-Guindy (1971) demonstrated increases in temperature and pulse rate as well as mydriasis in 30
people chewing khat. Subsequent studies describe moderate increases in blood pressure, transient
and conjunctival congestion, extra-systoles and increased respiratory rate. Inhibition of micurition,
increased diuresis (due to intake of large amounts of fluids while chewing), increased libido, impotence
and spermatorrhoea are also common (Halbach, 1979). Brownish staining of the teeth and mydriasis
with a staring gaze are considered pathognomonic signs of khat use (Kalix, 1987).
Unwanted effects associated with khat are sleeplessness, nervousness, impotence and nightmares
(Kennedy, 1987). Gastro-intestinal tract problems are common, such as anorexia and constipation
(Giannini et al. 1986). The latter is most likely due to the astringent effects of the tannins in khat
(Halbach, 1972), and laxative use is high in khat-chewing areas, the sale of laxatives decreasing
markedly when khat is prohibited (Luqman & Danowski, 1976). Khat has been implicated in a number
of other gastrointestinal and cardiovascular conditions (Halbach, 1972; Gendron et al. 1977; Giannini et
al. 1986). However, Kennedy et al. (1983; Kennedy, 1987) have questioned the extent of such
associations. Anorexia leads to malnutrition and increased susceptibility tom infectious diseases,
especially tuberculosis (Kalix, 1987). There is also increased prevalence of respiratory problems in men
, resulting from associated heavy smoking during khat sessions (Kennedy et al. 1983)
Endoctrine effects are variable (Giannini et al. 1986). Hyper glycaemia may occur in diabetes (Luqman
& Danowski, 1976). Reduced birth weight of babies (Kalix, 1987) and inhibition of lactation (Luqman
& Danowski, 1976) have been reported in khat-chewing mothers, possibly resulting from increased
dopamine production (Laurent, 1962a). Khat also causes an increase in adrenocorticotrophic hormone
and growth hormone, as do amphetamines (Nencini et al. 1983). Chromosomal abnormalities,
decreased mitosis and decreased synthesis of DNA, RNA and total protein have been reported in rat
studies (De Hondt et al. 1984).
Social Consequences of Khat Chewing
Individuals commonly divert their income into khat chewing, neglecting their families' needs (Kalix,
1987). The average family income can sometimes be halved to support the habit (Baasher & Sadoun,
1983). Khat has furthermore been implicated as a causal factor for family instability (Elm), 1983 b),
divorce (Baasher & Sadoun, 1983), encouragement of prostitution and criminal behaviour (Elmi 1983
Nationally, diversion of resources toward the production or importation and marketing of khat
has a negative impact on the economies of khat consuming countries. Baasher (1980) estimates that in
cities of Somalia and Yemen a consumer spends about 25%. of his daily earnings on khat. The
cultivation of khat results in the decreased production of other more essential crops like cereals,
promoting malnutrition and disease (Murad, 1983). It also leads to low productivity due to absenteeism
and the after-effects of its use (Halbach, 1972, 1979; Elmi, 1983b; Giannini et al. 1986; Kalix, 1987).
At the same time it is a major source of revenue. The concomitant use of alcohol to counteract the
stimulant and insomniac effects of khat (Kennedy, 1987; Omolo & Dadphale, 1987b) raises the risk of
complications from both these drugs (Omolo & Dhadphale, 1987b).
The khat session also serves an important social function in Yemeni society (Weir, 1985;
Kennedy, 1987). Despite the reduction in working hours spent on chewing khat (Eddy et al. 1965;
Halbach, 1979), Kennedy (1987) describes how these sessions can provide an arena for
communication where serious exchanges of ideas and information take place.
The Issue of Dependence:
In 1973, the WHO Expert Committee on Drug Dependence included khat type preparations of Catha
edulis Forsk, in their group of 'dependence-producing drugs'. In their 22nd report in 1985 cathine was
assessed as having a central stimulating action similar to amphetamine but about 7-10 times less potent.
Similarly, cathinone was regarded as a CNS stimulant about half as potent as amphetamine. Both
compounds were felt to meet the criteria for control under the Convention on Psychotropic Substances.
Eddy et al. (1965) assessed khat as causing a moderate but often persistent psychic
dependence, but no physical dependence or tolerance in contrast to the marked tolerance observed
with amphetamine abuse (Kennedy et al. 1980; Kennedy, 1987). This lack of an appreciable tolerance
to khat may be due to the physical limits on the amount that can be chewed (Halbach, 1972).
Tolerance may, however, develop to the sympathetic effects of khat (Nencini et al. 1984 a).
Kennedy (1987) considers that heavy khat chewers experience true withdrawal symptoms,
albeit relatively weak, of profound lassitude, anergia, difficulty in initiating their normal activities and a
slight trembling several days after ceasing to chew. In addition, he reported extremely unpleasant
dreams often of a paranoid nature of being attacked, strangled or followed (see also Halbach, 1972;
Gough & Cookson, 1984). These he interpreted as rebound phenomena rather than a specific
abstinence syndrome. It is considered that there are no physical symptoms on withdrawal from khat
(Luqman & Danowski, 1976; Giannini et al. 1986). The effect on health of stopping khat is generally
beneficial with improvement in sleep and appetite, fewer problems due to constipation and a decrease
in alcohol consumption (Luqman & Danowski, 1976).
The Psychoactive Effects of Khat Abuse
Subjectively, the pleasurable effects of khat are considered as beneficial (Kalix, 1987). These effects
are similar to those of amphetamine and include euphoria, increased alertness and excitement etc.
(Giannini et al. 1986). The khat user believes he thinks more clearly and quickly and is more alert,
though concentration and judgement are objectively impaired. There is a tendency to querulousness
with lability of mood and increases in anxiety and tension (Margetts,
1967). Kennedy (1987) has described transient psychotic phenomena following a khat session.
Confusion, disorientation, grandiose fantasies and a mildly depressed mood may occur. We report here
on three cases of khat related psychoses occurring in Somalian males in the UK.
Mr A. is a 31-year-old separated Somalian man who was admitted from prison to a medium secure
under section 31 of the Mental Health Act of 1983. He had been convicted of grievous bodily harm
following a knife attack on his landlord. He believed that the latter was using chemicals against him and
was trying to kill him.
Mr A. comes from a family of nine children. His father was described as mistrustful of people.
Both his parents died in 1982. A younger brother had been receiving treatment for a paranoid illness
and recently committed suicide. It is uncertain whether he abused khat.
He arrived in the UK as a refugee, seeking political asylum as he had been involved in
anti-government activities. He worked in the United Arab Emirates from 1976 until 1984 when he
started a business in Tanzania which failed. Premorbidly, he is described by his cousin as a quiet,
helpful, hard-working man with many friends. He had no prior involvement with the law nor received
any prior psychiatric care. In 1985 he had several episodes of malaria. Concurrently, he had been
chewing khat socially on a daily basis and drinking 2-4 litres of beer three times weekly. He describes
becoming suspicious that doctors were maltreating him for financial gain. It has not been possible
accurately to assess his mental state at that time.
Mr A. came to the UK six months prior to the offence. He continued to take khat but in lesser
amounts due to his financial circumstances. He was also socially isolated, even from the Somali
community. His alcohol consumption increased and within two months his mood had become
depressed. He chewed khat and drank on his own in contrast to his previous consumption in a social
setting. He slept badly, his self-care declined, his clothes became dirty and his appetite was poor. He
was bad tempered and changed in his personality. He developed delusions of persecution that
everybody was his enemy as well as nihilistic delusions that parts of his body were missing. He was
having nightmares that people were chasing him and heard them calling him a failure. He developed
delusions of reference relating to newspaper articles about him, he heard people talking indirectly
about his affairs and he thought that the Somali government was behind it all. He believed that his
cousin was conspiring with others to use 'psychochemical warfare' against him and was passing on all
his secrets. On the day prior to the offence he was chewing khat together with some Somalian friends
for about eight hours. He was unable to sleep and described the somatic hallucination of something cold
in his brain which was forcing itself out through his nostrils. He also experienced olfactory hallucinations
of chemicals in his room. At this point he suddenly developed the belief that his landlord was drugging
him and trying to kill him. He also realized that his cousin was like a robot as a result of these chemicals
and he believed he also was being turned into a robot. He went downstairs and stabbed his landlord in
the neck with a kitchen knife. While in prison his symptoms resolved rapidly on no medication. He
presented no management problem either in prison or while in hospital and did not receive any
medication. Investigations including EEG and urinalysis for drugs were negative.
Mr B. is a 27-year-old single Somali man who had worked as a clerk in Saudi Arabia. He was
first admitted informally to a psychiatric ward following three attempts to hang himself He had been
chewing khat heavily over the preceding year, sleeping poorly, feeling increasingly depressed and had
become convinced that people were calling him gay. He decided impulsively that the only way to deal
with this was by suicide.
A maternal uncle has had an unspecified mental illness for 10 years. There was no other
relevant family history. He came to the UK as a political refugee in 1985 because of his involvement in
an anti-government movement, and he believed that, were he to return to Somalia, he would be jailed
or killed. He described himself premorbidly as outgoing and sociable. His relationships had been
exclusively heterosexual. While in this country he lived a solitary life and had little contact with other
Somali people. There was no past medical or psychiatric history. He did not drink and denied drugs
other than khat which he had begun to chew excessively soon after his arrival in the United Kingdom.
He had been chewing khat daily, usually while alone and often borrowed money to buy it. On a
few occasions after chewing khat, Mr B. described severe anxiety with palpitations, feeling as though
he were going to have a heart attack and a fear that he would die. He also described spermatorrhoea.
During the two months prior to his admission, Mr B. had felt himself 'not normal' in some way and he
seemed irritable to his friends. His concentration, sleep, libido and appetite were poor and he had lost
about 20 kg in weight, which he put down to khat. He had begun to feel increasingly depressed, felt he
hated life and thought he would prefer to be dead. He warned constantly about his status as a refugee,
and was fearful about the prospect of returning to his country. Three weeks prior to admission he
developed ideas of reference that his friends were calling him a homosexual. He also believed that his
friends were using double meanings and that they were jealous of him because his family were well
known. He then stopped chewing khat for a period of one week as he thought he was becoming an
addict, but resumed it on the night prior to his admission when he decided to end it all. There were no
other psychotic features in his mental state. On physical examination he had marked brownish
discolouration of his teeth, bilateral conjunctival haemorrhages and abrasions around his neck and to his
leg (incurred during his suicide attempts). Investigations including urine drug screen were negative.
After admission his depressive symptoms rapidly resolved and he did not require any
medication. His sleep, appetite and concentration improved and he was discharged after 8 days. He
was re-admitted 2 weeks later, having recommenced khat. He was again depressed and believed that
his family were conspiring against him as well as continuing to believe that his friends were calling him
gay. His depressive symptoms resolved rapidly without medication. However, he complained of
continuing to feel suspicious. He was commenced on chlorpromazine 50 mg NCTE and discharged to
outpatient follow-up. Nine days later, Mr B. committed suicide and homicide by pouring petrol over
himself and a one-year-old child and setting himself alight. Over the preceding twenty-four hours he
was unable to sleep and was making threats to kill himself During this time his family remained awake
with him and had called the police because of their concern, though they were unaware of his homicidal
intentions. The family believe he had recommenced chewing khat.
Mr C. is a 36-year-old Somali man who had been in England on a grant for further studies in
accountancy. He has had a number of admissions to a psychiatric hospital with a hypomanic illness
since 1983. Premorbidly he was described as a quiet, introverted. pleasant and hardworking man.
There is no family history of psychiatric ill-health. Since the onset of his illness, Mr C. has been in
trouble with the Somali Government and has become persona non "rata and is apparently threatened
with arrest should he return to Somalia.
He was first admitted to hospital in August 1983 after failing his exams when he was in a hyperactive
state with grandiose ideas that he could summon power from heaven by running both taps in the sink.
He quickly settled, but was readmitted 3 weeks after discharge with a 3-day history of sleeplessness
and disinhibited, aggressive behaviour. He was treated with chlorpromazine and lithium and settled
within six weeks. He remained well until August 1986, when he became violent at a friend's house. He
had also left all the taps running in his flat and had been running naked in the street saying that, as he
was born that way, he would go back to Djibouti to liberate his country in the same way. Prior to each
admission he had been preparing for examinations and had been chewing increasing amounts of khat.
Both the British Consulate and his family felt his relapses were related to his chewing of khat.
Features of the khat-induced psychoses
Psychoses due to khat are considered by many authors to be rare phenomena (Kalix, 1987; Baasher,
1980; Halbach, 1972). Halbach (1972) believes this is the result of the way in which khat is ingested,
thereby not permitting high blood levels of its active ingredients. Luqman & Danowski (1976),
however, make the point that in khat-using areas where health facilities are lacking, persons with
psychosis are usually locked in their homes by their families until the episode subsides.
The first cases of khat-induced psychosis were reported by Carothers in 1945. Tables I & 2
summarize the features of the cases to date, including the three cases reported here. As can be seen,
the ages range from 20 to 36 with a predominance of males, there being only one female case. In only
two of the twelve cases was there a past psychiatric history and in one of these cases the onset of
psychosis was probably related to khat abuse. A family history of psychiatric illness was present in two
cases of the six cases where this information was recorded. Pre-morbid functioning was considered
normal in the six cases where this was reported. Social isolation was a feature in only three cases,
though the solitary use of khat was apparent in half of them.
In all twelve cases the psychosis developed after a recent heavy or increased use of khat. The
episode rapidly resolved within one to two weeks of stopping khat in all but one case. There was a
tendency for the psychosis to recur with the recommencement of khat. Not enough information was
available to draw any conclusions about level of functioning between episodes of psychosis, though in at
least five cases they were considered to be normal. Neuroleptics were used in nearly all of the cases.
However, the time course for symptom resolution suggests that it was the withdrawal of the drug which
was important. This was notably seen in the case of Mr B., who also relapsed rapidly with
reinstatement of khat chewing. Other authors have made similar observations (e.g. Luqman &
Danowski, 1976). The concomitant use of alcohol or other drugs was only reported in one case despite
the literature suggesting a high prevalence of associated alcohol use (Omolo & Dhadphale, 19875).
Table 2 describes the phenomena observed in these psychotic patients. Interestingly, paranoid
delusions were not a constant theme (cf. amphetamine psychosis, below) though when present they
tended to dominate the picture. Two types of reaction seem most apparent. First, there is a paranoid
psychosis with prominent delusions of persecution often associated with auditory hallucinations. This
pattern most closely resembles the paranoid psychosis seen with amphetamines and is discussed further
below. Other first rank symptoms, for example, thought broadcast and passivity experiences, were also
present in this subgroup of khat psychotics. A second reaction seen in five cases was of a manic illness
with grandiose delusions, usually without auditory hallucinations. A less common response is of a
depressive illness, which occurred in two of our cases. This could have resulted from a relative
decrease in khat intake preceding a further heavy khat session, at which time the paranoid delusions
became prominent. No mention is made of depressed mood in any of the other cases, in particular, that
reported by Critchlow & Seifert (1987) in which there was attempted suicide.
The case by McLaren (1987) is atypical in that a one-year history of progressively odd
behaviour precedes the onset of a psychotic reaction which was precipitated by khat. Such an effect
has been discussed by other authors (Halbach, 1972; Carothers, 1945; Laurent, 1962a,b). The issue of
vulnerability of the individual to the effects of a particular drug have been considered by other authors
reviewing amphetamine psychosis (Gold & Bowers, 1978). They postulate that in patients developing a
psychotic reaction to low doses of amphetamine there exists a vulnerability which requires the drug to
make the psychosis manifest. Large doses of amphetamine, however, will produce psychosis in
individuals who do not necessarily have this susceptibility. This may be relevant for khat induced
psychosis, as khat has a lower potency than amphetamine and large increments in dose are limited by
its mode of administration.
Confusional states following khat usage are considered rare by most authors (Halbach,1979;
Giannini et al. 1986; Kalix, 1987) and Dhadphale & Mengech (1987) and Dhadphale et al. (1981)
make the point that the paranoid reactions observed occur in a setting of clear consciousness. Kennedy
(1987), on the other hand, states that confusion and disorientation may occur as a transient
phenomenon in the khat-user, even without psychosis.
Relationship to other psychostimulants
Luqman & Danowski (1976) draw parallels with psychosis due to amphetamines and this is also
discussed by Ellinwood (1969). Connell (1958) states that the main distinguishing feature of
amphetamine psychosis, compared with other organic psychoses, is the relative absence of
disorientation and confusion. A number of other features of the psychiatric presentation of amphetamine
use also bear a close resemblance to those of khat. Of particular interest is the well delineated,
characteristic nature of amphetamine psychosis with a high proportion of paranoid delusions, auditory
and visual hallucinations, although the tactile and olfactory modalities may also be involved. These
symptoms worsen with acute increases in dosage of the drug. Those amphetamine abusers who
developed psychosis differed from non-psychotic abusers by the presence of intense fear and terror
(Ellinwood, 1969). Similar symptoms were prominent in six of the reported cases (see Table 2), all of
whom were paranoid psychotics. This occasionally led to attempted suicide in amphetamine users
(Ellinwood, 1969). However, suicide is also a danger during the withdrawal period (Cornell, 1958). In
the case of Mr B., his initial suicide attempts followed a heavy khat session after a week without the
drug, during which his depressive symptoms worsened. Similarly, Mr A. had decreased his
consumption of khat to some extent since arriving in the UK and his paranoid symptoms were
heightened by a heavy session of khat chewing. In the case reported by Critchlow & Seifert (1987), the
relationship of the suicide attempt to either withdrawal of the drug or to symptoms related to its abuse is
not made clear.
Amphetamine abusers who developed psychosis also differed from the non-psychotic abuser
by the presence of olfactory and tactile hallucinations, as were evidenced in the case of Mr A.
Delusions of infestation occurred in up to 50% of amphetamine abusers (both psychotic and
nonpsychotic) and Kennedy (1987) describes the most common hallucination amongst khat users as
being 'the feeling of hundreds of insects crawling over the body'. Ellinwood (1969, 1971) also
highlights the effect of the environment on the content of delusions. Thus the real possibility of the addict
being followed by the police became incorporated into their delusional system. A similar reaction is
observed in the case of Mr A. who was a political refugee from Somalia, with his fears relating to the
Somali government becoming part of his delusional system. Snyder (1973), in discussing amphetamine
psychosis as a possible model for schizophrenia, postulates that it is the alerting effects, mediated by
noradrenergic pathways, which lead to the development of a system of paranoid delusions. This author
discusses the possible roles of dopamine and noradrenergic systems in the development of such a
Ephedrine psychosis has been recently considered by Whitehouse & Duncan (1987), who have
reviewed 20 reported cases as well as their own. The typical clinical picture was again of a paranoid
psychosis with prominent delusions and hallucinations in a setting of clear consciousness. This is relevant
to khat, which contains norpseudoephedrine, as well as the more potent cathinone. Thus, these
sympathomimetics are more likely to induce psychosis by acting in combination than by acting alone. In
the USA, ephedrine and other non-controlled sympathomimetics are freely available over the counter
and have become some of the most commonly abused drugs (Siegel. 1980; Doughtery, 1982;
Whitehouse, 1987). Concern about ephedrine abuse has also been expressed in the UK as early as
The relationship of amphetamine abuse to assault and homicide are discussed at length by
Ellinwood (1971). A number of important features are brought out in his investigation of 13 cases. In
particular there seemed to be a relationship with recent increase in drug dosage in the context of a
pre-morbid solitary lifestyle in persons with poor impulse control. Sleeplessness was often a factor, as
was the associated use of sedative drugs including alcohol, which Ellinwood feels had a disinhibiting
effect. The act itself was usually impulsive rather than planned, although a concealed weapon was a
feature in all but one of the cases. Similarities can be seen with the cases of Mr A. and Mr B. who were
both involved in violent acts and who both led rather solitary lives since arriving in the UK. In the case
of Mr A., a heavy bout of khat consumption together with alcohol and a sleepless night preceded the
attack on his landlord. In Mr B.'s case his suicide-homicide was preceded by insomnia and there was
little warning of his homicidal intentions. Two other cases are reported, in the literature, in which the
patients were carrying weapons (Dhadphale et al. 1981; Gough & Cookson, 1984), although there
were no actual aggressive acts.
Cultural aspects of khat abuse
Jaffe ( 1980) makes the distinction between culturally integrated and culturally less-integrated drug use,
believing this to be of greater importance to deviant behaviour related to drugs than is the nature of the
drug itself. A parallel may be drawn to the use of khat in the UK as opposed to the country of origin,
such dislocation setting the scene for a more deviant pattern of drug abuse. In the above cases, the
pattern of khat and alcohol abuse was very different to the culturally accepted pattern, with the drug
often being taken alone and thereby no longer functioning as a means of facilitating social interchange.
This estrangement of these individuals from their home country, where the khat habit is subject to
identifiable rules, may have placed this group at an increased risk from the detrimental effects of khat
use. Giannini & Castellani ( 1982) reinforce this view, stating that, first, the customary patterns of
usages in the culture of origin tend to limit the amount of drug used daily and secondly, khat chewing is
condoned in such countries and is thus done in a social context which gives positive reinforcement and
meaning to the experience.
Legislation against khat usage?
The seriousness of the cases described has resulted in public concern regarding the need for legislation
to limit the sale of khat in the UK (Busby, 1987). D'Orban has reviewed this issue with regard to other
drugs. He states that legislation to control the non-medical use of drugs through criminal law is usually a
response to some form of change in the pattern of drug consumption (D'Orban, 1986). Historically,
these legislative controls have arisen piecemeal and in response to a series of crisis situations, initially
with amphetamines and then heroin and cocaine. D'Orban (1986) concludes that 'the history of drug
control policies leads to the pessimistic view that they are relatively ineffective and that drug problems
cannot be dealt with in isolation from the international context'.
The trade and usage of khat in Great Britain is presently not illegal, and it is known that there is
a market and distribution network for the drug, with its substantial use in certain locations (Hog" &
Rogers, 1985; Kalix, 1987). Critchlow & Seifert (1987) estimate that extremely large numbers of the
Somali community in London (estimated at about 4000) use khat. Kalix (1987) states that European
countries have relatively little to fear from khat owing to its unattractive 'goat-like' mode of consumption
and its relatively low potency, as well as the difficulty involved in extracting cathinone (cf. cocaine from
coca leaves). Mayberry et al. (1984), on the other hand, believe that its use will become more
extensive as the second generation of those ethnic minorities accustomed to its use become integrated
into Western society. They also point out that with the development of air travel, fresh khat leaves can
be distributed rapidly, thereby making khat readily available in the West. There have already been some
reports of the use of khat by Westerners in this country (Hog" & Rogers, 1985). The possible need for
preventive scheduling needs to be considered before an increase in the habit, particularly in immigrant
groups, leads to problems. Kalix (1987) concludes that 'a limitation of khat use is desirable
as the spread of the habit in recent years is worrying'. The International Council on Alcohol and
Addiction (Shanhandeh et al. 1983) have advised that those countries involved with the problem of
khat deal with it in their own specific context. The extent of the problem in the United Kingdom is
limited. However, in view of the seriousness of two of the cases reported the present authors feel that
the growing use of khat needs to be closely monitored.
- Khat chewing has been widespread in various Middle Eastern countries and is increasing in
frequency amongst immigrant groups in the West. There is evidence to suggest that the habit may be
spreading beyond such ethnic groups.
- The active ingredient in khat, cathinone, is closely related to amphetamine in structure and effects.
- From a review of the literature and our own cases it appears that khat chewing can induce at least
two kinds of psychotic reaction: a paranoid psychosis with prominent persecutory delusions associated
with intense fear and anxiety, with or without auditory hallucinations, in a setting of clear consciousness,
and a hypomanic illness with grandiose delusions. In both forms of presentation symptoms abated
rapidly when khat was withdrawn.
- Acts of violence were exhibited in recent cases in which paranoid delusions were prominent, these
having similarities to amphetamine psychotics involved in violent acts.
We would like to thank Dr P. T. D'Orban and Dr T. R. E. Barnes for their helpful criticisms of the text,
as well as Professor A. Wakeling and Dr D. Pitcher for permission to interview and review the notes of
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