Hallucinogen persisting perception disorder | |
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HPPD noise simulation, often referred to as visual snow | |
Specialty | Psychiatry |
Hallucinogen persisting perception disorder (HPPD) is a non-psychotic disorder in which a person experiences apparent lasting or persistent visual hallucinations or perceptual distortions after using drugs, [1] including but not limited to psychedelics, dissociatives, entactogens, tetrahydrocannabinol (THC), and SSRIs. [2] [3] Despite being designated as a hallucinogen-specific disorder, the specific contributory role of psychedelic drugs is unknown.
The hallucinations and perceptual changes consist of, but are not limited to, visual snow, trails and after images (palinopsia), light fractals on flat surfaces, intensified colors, altered motion perception, pareidolia, micropsia, and macropsia. [3] People who have never previously taken drugs have also reported some symptoms associated with HPPD (such as floaters and visual snow). [4] [5]
HPPD is a DSM-5 diagnosis with diagnostic code 292.89 (F16.983). [6] For the diagnosis to be made, other psychological, psychiatric, or neurological conditions must be ruled out and it must cause distress in everyday life. [6] In the ICD-10, the diagnosis code F16.7 corresponds most closely to the clinical picture. HPPD is rarely recognized amongst both hallucinogen users and psychiatrists, and is often misdiagnosed as a substance-induced psychosis.
Newer research makes a distinction between HPPD I and HPPD II. [3] The more drastic cases, as seen in HPPD II, are believed to be caused by the use of psychedelics as well as comorbid mental disorders. [3] Some people who have this disorder report that they developed symptoms of HPPD after their first use of such drugs (most notably LSD). Because research regarding HPPD is currently lacking, there is little information on effective treatments, its aetiology and relationship to other disorders, and precise mechanism. [7]
In 1898, the English physician and intellectual Havelock Ellis reported a heightened sensitivity to what he described as "the more delicate phenomena of light and shade and color" for a prolonged period of time after he was exposed to the hallucinogenic drug mescaline. This may have been one of the first recorded symptoms of what would later be called HPPD. [8] Hallucinogen-persisting perception disorder was first described in 1954, [9] with other observations made in early psychedelic research. [10] Horowitz [11] first introduced the term flashbacks, referring to recurrent and spontaneous perceptual distortions and unbidden images. When these "flashbacks" present as recurrent, but without a current acute, or chronic hallucinogen intake, the disturbance is referred to as HPPD. Horowitz classified also three types of visual flashbacks: (a) perceptual distortions (e.g., seeing haloes around objects); (b) heightened imagery (e.g., visual experiences as much more vivid and dominant in one's thoughts); and (c) recurrent unbidden images (e.g., subjects see objects that are not there). LSD therapist Stanislav Grof noted an HPPD phenomenon in his book LSD Psychotherapy from 1978, which noted that "[l]ong after the pharmacological effect of the drug has subsided, the patient may still report anomalies in color-perception, blurred vision, after-images, spontaneous imagery, alterations in body image, intensification of hearing, ringing in the ears, or various strange physical feelings."
HPPD has been introduced under the diagnosis of Post-hallucinogen Perception Disorder in 1987 within the DSM-III-R. [12] Subsequently, the DSM-IV-TR [13] recognized the syndrome as Hallucinogen-Persisting Perception Disorder (Flashbacks) (code 292.89) (15). The Neurosensory Research Foundation [14] was founded by HPPD sufferers to promote research and awareness around the condition. Subsequently, in 2021, the Perception Restoration Foundation [15] was launched to bolster efforts for research, awareness and harm reduction. In 2022, journalists at Psymposia and New York Magazine revealed that a participant in MAPS' landmark MDMA trials for PTSD developed post-psychedelic visual effects similar to HPPD. [16] [ time needed ] Subclinical HPPD phenomena have occurred in other trial settings. [17]
Typical symptoms of the disorder include: halos or auras surrounding objects, trails following objects in motion, difficulty distinguishing between colors, apparent shifts in the hue of a given item, the illusion of movement in a static setting, visual snow, distortions in the dimensions of a perceived object, intensified hypnagogic and hypnopompic hallucinations, monocular double vision, seeing an excessive amount of eye floaters, the morphing of multiple objects into one texture, and blue field entoptic phenomenon. The visual alterations experienced by those with HPPD are not homogeneous and there appear to be individual differences in both the number and intensity of symptoms. [18]
Visual aberrations can occur periodically in healthy individuals – e.g., afterimages after staring at a light, noticing floaters inside the eye, blue field entoptic phenomenon or seeing specks of light in a darkened room. However, in people with HPPD, symptoms seem typically to be worse, but complication comes from the additional roles played anxiety and fixation. Indeed, anxiety has been implicated in visual perceptual effects similar to HPPD, [19] and authors have recognized the crucial role of attending to underlying anxiety and panic in recovering from the disorder.
There is some uncertainty about to what degree visual snow constitutes a true HPPD symptom. There are individuals who have never used a drug which could have caused the onset, but yet experience the same grainy vision reported by those with HPPD, like people with the closely-linked neurological disorder known as visual snow syndrome. [20] There are a few potential reasons for this, the most obvious of which being the theory that the drug usage may exaggerate the intensity of visual snow. At the same time, beyond the characteristic visual snow symptom, there is considerable overlap between the conditions, including after-images, palinopsia, tinnitus, dissociation and free-floating anxiety, leading some to suggest that HPPD shares a strong relationship with visual snow syndrome. [21] Visual snow syndrome is defined as lacking any known cause and is specifically distinguished from HPPD in its nosology, yet further research may clarify the relationship. HPPD usually has a visual manifestation, but some hallucinogenic and psychiatric drugs affect the auditory sense and can produce tinnitus-like symptoms as a side effect, and there are many anecdotal reports of people getting tinnitus with their HPPD.[ citation needed ]
A significant number of those reporting HPPD also describe comorbid depersonalization-derealization and anxiety disorders. [1] Anxiety, PTSD [22] [23] and panic [24] can promote depersonalization-derealization [25] and visual disturbances, and vice versa, so these features may run in multidirectional relationships. Abraham suggested that all three can arise from a broader mechanism of disinhibition in sensory perception, affect and sense-of-self occasioned by psychedelic experience. It is not uncommon for depersonalization-derealization to be the most distressing symptom of the condition.
According to a 2016 review, there are two theorized subtypes of the condition. [26] [6] Type 1 HPPD is where people experience random, brief flashbacks. [6] Type 2 HPPD entails experiencing persistent changes to vision, which may vary in intensity. [6] This model has faced scrutiny, however, due to "flashbacks" often being considered a separate condition and not always a perceptual one. [7]
A vast list of psychoactive substances has been identified and linked with the development of this condition, including lysergamides like LSD and LSA, tryptamines like psilocybin and DMT, phenethylamines like 2C-B, MDMA, MDA and mescaline. [27] [3] Dissociatives such as ketamine and dextromethorphan as well as cannabis and synthetic cannabinoids, salvia divinorum, datura and iboga are also known to trigger HPPD. [3] It is therefore clear that HPPD is not strictly associated with psychedelic consumption as a number of hallucination-inducing substances may be correlated with its arising. [3] For some, the dosage and how frequently one uses these substances does not seem to matter in the development of this condition, since there are several reports in the literature where patients were diagnosed after a single use. [3] This strongly indicates that there may be a genetic predisposition to this condition. It also seems that combining recreational or medical drugs that act on the 5HT2-a receptors, like SSRIs, drastically increases the chances of developing HPPD due to the drug-drug interaction. [28] HPPD is not related to psychosis due to the fact people affected by the disorder can easily distinguish their visual disturbances from reality. [29] Which drugs are most prone to causing HPPD is not entirely known. While LSD has been described as the leading cause of HPPD, this may be a function of LSD's historically higher relative popularity as a recreational psychedelic drug. [1] Popularity effects may explain the high proportion of cases precipitated by cannabis. A 2022 clinical review found no significant difference in the induction of subclinical visual phenomena between MDMA, LSD and psilocybin. [17] Curiously, lasting visual effects have also occurred as complications of benzodiazepine withdrawal syndrome. [30]
The exact pathophysiologic mechanism underlying HPPD is poorly understood. The primary neurobiological hypothesis is that persistent hallucinations are the result of chronic disinhibition of visual processors and subsequent dysfunction in the central nervous system following consumption of hallucinogens. [31] [32] Chronic disinhibition may occur from destruction and/or dysfunction of cortical serotonergic inhibitory interneurons involving the inhibitory neurotransmitter, gamma-aminobutyric acid (GABA). [33] [34] [35] [36] This ultimately can cause disruption of the normal neurological mechanisms that are responsible for filtration of unnecessary stimuli in the brain. On a macroscopic level, the lateral geniculate nucleus (LGN) of the thalamus, which is important in visual processing, has also been implicated in the pathophysiology of HPPD. [37]
Other researchers have suggested HPPD may be related to drug-induced elevations in neuroplasticity [38] – an effect also noted to occur for SSRIs. [39] Reverse neuroplasticity effects may account for anecdotal reports of individuals treating their HPPD symptoms with further psychedelic drug use, while others report significant deterioriations in their symptoms.[ citation needed ]
Being characterized by clinical distress and impairment, however, HPPD is also shaped by psychosocial factors. There is tentative evidence that those who develop distressing HPPD have higher trait anxiety, [40] or experienced elevations in baseline anxiety from possibly negative psychedelic experiences. [26] Elevations in anxiety, and anxious responses to visual and related symptoms, may provoke direct elevations in symptom intensity and fuel the distress that defines HPPD as a clinical entity. Certain core beliefs and automatic thoughts are observed to occur among those reporting HPPD: fears of brain damage, a 'never-ending trip', the development of schizophrenia or a related psychosis spectrum disorder, a more generalized concern surrounding insanity, and destructive thoughts concerning the loss of one's previous self or a new identity centred on brokenness and alienation from others.[ citation needed ] Being a drug-related disorder, HPPD is therefore vulnerable to internalized anti-drug stigma, specifically around 'flashbacks' and 'brain frying', which were heavily propagandized in prohibitionist campaigns in the 20th-century. [41]
As of January 2022 there is no officially recognized cure or therapy for HPPD, but those affected with HPPD are heavily advised to discontinue all recreational drug use. Improving sleep quality, reducing anxiety, lowering screen use, improving diet quality and pursuing regular exercise are encouraged as general lifestyle changes. To decrease fixation and monitoring behaviors with visual symptoms, increased focus on external tasks may also be encouraged.[ citation needed ]
Antipsychotics such as aripiprazole or risperidone, intended to treat mental disorders like schizophrenia, should only be taken in careful consultation with a psychiatrist experienced in HPPD. The success rate of antipsychotics as a treatment method for HPPD is still debated. Two young men with HPPD and schizophrenia as a comorbidity experienced a remission of visual perceptual disturbance during a 6-month follow-up observation under treatment with risperidone. [42] There was a case study in 2013 where oral risperidone was also successful for treating HPPD. [43] In other cases risperidone has shown no effect on HPPD [42] or where it had a paradoxical effect and lead to permanent symptom exacerbation. [44]
A 2022 case reported indicated promise for brain stimulation therapy for a longstanding HPPD patient. [49]
Outside of pharmacotherapy, recovery from HPPD as a clinical entity – that, is involving distress and impairment – can come about through psychological and social means. Case reports of psychotherapy for HPPD suggest that anxiety reduction, muscle relaxation, and re-framing one's visual phenomena through personal destigmatization and normalization may be helpful. [50] [51] [52] [53] Some authors have suggested that HPPD be better designated as a particular somatic symptom disorder [5] rather than a disorder defined centrally by hallucinogen use. Cognitive behavioral therapy has shown promise for somatic symptom disorders, [54] as well as related distress from tinnitus. CBT has likewise shown promise for depersonalization-derealization disorder, [55] which occurs as a common comorbidity to HPPD and seems to share many of the same catastrophic thoughts. [56] The Perception Restoration Foundation hosts a Specialists Directory that lists professionals with prior experience or relevant expertise in helping those with HPPD. [57]
In a 2010 optional online survey of psychedelic users seeking medical information, 60% reported recurring HPPD-like effects, though only 4.2% considered seeking treatment due to the severity. The authors concede occurrences are rare but suggest the survey supports a need for further research. [58] In a 2022 double-blind, placebo-controlled study, 142 subjects received LSD, psilocybin, or both, reported no cases of HPPD, and up to 9.2% of the subjects had flashbacks which were "transient, mostly experienced as benign and did not impair daily life". [17]
In 1971, Shelagh McDonald vanished from the world of folk music after experiencing severe HPPD, losing contact with the entire industry until 2005.
In the second episode of the first season of the 2014 series True Detective ("Seeing Things"), primary character Rustin Cohle (Matthew McConaughey) is depicted as having symptoms similar to HPPD such as light tracers as a result of "neurological damage" from substance use. [59]
American journalist Andrew Callaghan, former host of the internet series All Gas No Brakes and current host of Channel 5, revealed during a 2021 interview with Vice News that he experiences the symptoms of HPPD as a result of psilocybin use at a young age. Describing his symptoms, he noted that he experiences persistent visual snow and palinopsia. [60]
American YouTuber and musician Matt Watson, known for cohosting the YouTube channel with over 1 million subscribers known as SuperMega, has revealed in a podcast interview with bbno$ that he acquired HPPD as a result of LSD use at the age of 22. [61] He stated that he experiences several persistent floaters in his vision, constant visual "static", and various other symptoms associated with HPPD.[ citation needed ]
Lysergic acid diethylamide, commonly known as LSD, and known colloquially as acid or lucy, is a potent psychedelic drug. Effects typically include intensified thoughts, emotions, and sensory perception. At sufficiently high dosages, LSD manifests primarily mental, visual, and auditory hallucinations. Dilated pupils, increased blood pressure, and increased body temperature are typical.
Psilocybin is a naturally occurring psychedelic prodrug compound produced by more than 200 species of fungi. The most potent are members of genus Psilocybe, such as P. azurescens, P. semilanceata, and P. cyanescens, but psilocybin has also been isolated from approximately a dozen other genera. Psilocybin is itself biologically inactive but is quickly converted by the body to psilocin, which has mind-altering effects similar, in some aspects, to those of lysergic acid diethylamide (LSD), mescaline, and dimethyltryptamine (DMT). In general, the effects include euphoria, visual and mental hallucinations, changes in perception, distorted sense of time, and perceived spiritual experiences. It can also cause adverse reactions such as nausea and panic attacks.
Psychopharmacology is the scientific study of the effects drugs have on mood, sensation, thinking, behavior, judgment and evaluation, and memory. It is distinguished from neuropsychopharmacology, which emphasizes the correlation between drug-induced changes in the functioning of cells in the nervous system and changes in consciousness and behavior.
Psychedelics are a subclass of hallucinogenic drugs whose primary effect is to trigger non-ordinary mental states and a perceived "expansion of consciousness". Also referred to as classic hallucinogens or serotonergic hallucinogens, the term psychedelic is sometimes used more broadly to include various types of hallucinogens, such as those which are atypical or adjacent to psychedelia like salvia and MDMA, respectively.
A bad trip is a term describing an acute adverse psychological reaction to effects produced under the influence of psychoactive substances, namely psychedelics. There is no clear definition of what constitutes a bad trip. Additionally, knowledge on the cause of bad trips and who may be vulnerable to such experiences are limited. Existing studies report that possible adverse reactions include, anxiety, panic, depersonalization, ego dissolution, paranoia, as well as physiological symptoms such as dizziness and heart palpitations. However, most studies indicate that the set and setting of substance use influence how people respond.
Hypochondriasis or hypochondria is a condition in which a person is excessively and unduly worried about having a serious illness. Hypochondria is an old concept whose meaning has repeatedly changed over its lifespan. It has been claimed that this debilitating condition results from an inaccurate perception of the condition of body or mind despite the absence of an actual medical diagnosis. An individual with hypochondriasis is known as a hypochondriac. Hypochondriacs become unduly alarmed about any physical or psychological symptoms they detect, no matter how minor the symptom may be, and are convinced that they have, or are about to be diagnosed with, a serious illness.
Risperidone, sold under the brand name Risperdal among others, is an atypical antipsychotic used to treat schizophrenia and bipolar disorder. It is taken either by mouth or by injection. The injectable versions are long-acting and last for 2–4 weeks.
Micropsia is a condition affecting human visual perception in which objects are perceived to be smaller than they actually are. Micropsia can be caused by optical factors, by distortion of images in the eye, by changes in the brain, and from psychological factors. Dissociative phenomena are linked with micropsia, which may be the result of brain-lateralization disturbance.
Dissociatives, colloquially dissos, are a subclass of hallucinogens that distort perception of sight and sound and produce feelings of detachment – dissociation – from the environment and/or self. Although many kinds of drugs are capable of such action, dissociatives are unique in that they do so in such a way that they produce hallucinogenic effects, which may include dissociation, a general decrease in sensory experience, hallucinations, dream-like states or anesthesia. Despite most dissociatives' main mechanism of action being tied to NMDA receptor antagonism, some of these substances, which are nonselective in action and affect the dopamine and/or opioid systems, may be capable of inducing more direct and repeatable euphoria or symptoms which are more akin to the effects of typical "hard drugs" or common drugs of abuse. This is likely why dissociatives are considered to be addictive with a fair to moderate potential for abuse, unlike psychedelics. Despite some dissociatives, such as phencyclidine (PCP) possessing stimulating properties, most dissociatives seem to have a general depressant effect and can produce sedation, respiratory depression, nausea, disorientation, analgesia, anesthesia, ataxia, cognitive and memory impairment as well as amnesia.
Depersonalization is a dissociative phenomenon characterized by a subjective feeling of detachment from oneself, manifesting as a sense of disconnection from one's thoughts, emotions, sensations, or actions, and often accompanied by a feeling of observing oneself from an external perspective. Subjects perceive that the world has become vague, dreamlike, surreal, or strange, leading to a diminished sense of individuality or identity. Sufferers often feel as though they are observing the world from a distance, as if separated by a barrier "behind glass". They maintain insight into the subjective nature of their experience, recognizing that it pertains to their own perception rather than altering objective reality. This distinction between subjective experience and objective reality distinguishes depersonalization from delusions, where individuals firmly believe in false perceptions as genuine truths. Depersonalization is also distinct from derealization, which involves a sense of detachment from the external world rather than from oneself.
Lamotrigine, sold under the brand name Lamictal among others, is a medication used to treat epilepsy and stabilize mood in bipolar disorder. For epilepsy, this includes focal seizures, tonic-clonic seizures, and seizures in Lennox-Gastaut syndrome. In bipolar disorder, lamotrigine has not been shown to reliably treat acute depression in any groups except for the severely depressed; but for patients with bipolar disorder who are not currently symptomatic, it appears to reduce the risk of future episodes of depression.
Psychedelic therapy refers to the proposed use of psychedelic drugs, such as psilocybin, MDMA, LSD, and ayahuasca, to treat mental disorders. As of 2021, psychedelic drugs are controlled substances in most countries and psychedelic therapy is not legally available outside clinical trials, with some exceptions.
Visual snow syndrome (VSS) is an uncommon neurological condition in which the primary symptom is that affected individuals see persistent flickering white, black, transparent, or colored dots across the whole visual field.
Palinopsia is the persistent recurrence of a visual image after the stimulus has been removed. Palinopsia is not a diagnosis; it is a diverse group of pathological visual symptoms with a wide variety of causes. Visual perseveration is synonymous with palinopsia.
Hallucinogens are a large and diverse class of psychoactive drugs that can produce altered states of consciousness characterized by major alterations in thought, mood, and perception as well as other changes. Most hallucinogens can be categorized as either being psychedelics, dissociatives, or deliriants.
Henry David Abraham is an American physician. He was a Clinical Professor of Psychiatry at Tufts University School of Medicine in Boston, Massachusetts.
A psychoactive drug, mind-altering drug, or consciousness-altering drug is a chemical substance that changes brain function and results in alterations in perception, mood, consciousness, cognition, or behavior. The term psychotropic drug is often used interchangeably, while some sources present narrower definitions. These substances may be used medically; recreationally; to purposefully improve performance or alter one's consciousness; as entheogens for ritual, spiritual, or shamanic purposes; or for research, including psychedelic therapy. Some categories of psychoactive drugs, which have therapeutic value, are prescribed by physicians and other healthcare practitioners. Examples include anesthetics, analgesics, anticonvulsant and antiparkinsonian drugs as well as medications used to treat neuropsychiatric disorders, such as antidepressants, anxiolytics, antipsychotics, and stimulant medications. Some psychoactive substances may be used in the detoxification and rehabilitation programs for persons dependent on or addicted to other psychoactive drugs.
Illusory palinopsia is a subtype of palinopsia, a visual disturbance defined as the persistence or recurrence of a visual image after the stimulus has been removed. Palinopsia is a broad term describing a heterogeneous group of symptoms, which is divided into hallucinatory palinopsia and illusory palinopsia. Illusory palinopsia is likely due to sustained awareness of a stimulus and is similar to a visual illusion: the distorted perception of a real external stimulus.
Psychoplastogens are a group of small molecule drugs that produce rapid and sustained effects on neuronal structure and function, intended to manifest therapeutic benefit after a single administration. Several existing psychoplastogens have been identified and their therapeutic effects demonstrated; several are presently at various stages of development as medications including ketamine, MDMA, scopolamine, and the serotonergic psychedelics, including LSD, psilocin, DMT, and 5-MeO-DMT. Compounds of this sort are being explored as therapeutics for a variety of brain disorders including depression, addiction, and PTSD. The ability to rapidly promote neuronal changes via mechanisms of neuroplasticity was recently discovered as the common therapeutic activity and mechanism of action.
Psychedelic treatments for trauma-related disorders are the use of psychedelic substances, either alone or used in conjunction with psychotherapy, to treat trauma-related disorders. Trauma-related disorders, such as post-traumatic stress disorder (PTSD), have a lifetime prevalence of around 8% in the US population. However, even though trauma-related disorders can hinder the everyday life of individuals with them, less than 50% of patients who meet criteria for PTSD diagnosis receive proper treatment. Psychotherapy is an effective treatment for trauma-related disorders. A meta-analysis of treatment outcomes has shown that 67% of patients who completed treatment for PTSD no longer met diagnostic criteria for PTSD. For those seeking evidence-based psychotherapy treatment, it is estimated that 22-24% will drop out of their treatment. In addition to psychotherapy, pharmacotherapy (medication) is an option for treating PTSD; however, research has found that pharmacotherapy is only effective for about 59% of patients. Although both forms of treatment are effective for many patients, high dropout rates of psychotherapy and treatment-resistant forms of PTSD have led to increased research in other possible forms of treatment. One such form is the use of psychedelics.