Hallucinogen persisting perception disorder

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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.

Contents

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]

History

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]

Symptoms

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 floaters 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]

Causes

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]

Pathophysiology

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. 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]

Treatment

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]

Prevalence

In a 2010 study of psychedelic users, 23.9%[ verification needed ] reported constant HPPD-like effects, though only 4.2% considered seeking treatment due to the severity. [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]

Society and culture

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 ]

Related Research Articles

<span class="mw-page-title-main">LSD</span> Hallucinogenic drug

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.

<span class="mw-page-title-main">Psilocybin</span> Chemical compound found in some species of mushrooms

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 about 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.

<span class="mw-page-title-main">Psychopharmacology</span> Study of the effects of psychoactive drugs

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.

<span class="mw-page-title-main">Psychedelic drug</span> Hallucinogenic class of psychoactive drug

Psychedelics are a subclass of hallucinogenic drugs whose primary effect is to trigger non-ordinary mental states and an apparent 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.

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

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<span class="mw-page-title-main">Micropsia</span> Medical condition

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.

<span class="mw-page-title-main">Depersonalization</span> Anomaly of self-awareness

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<span class="mw-page-title-main">Visual snow syndrome</span> Visual impairment

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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.

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Henry David Abraham is an American physician. He was a Clinical Professor of Psychiatry at Tufts University School of Medicine in Boston, Massachusetts.

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<span class="mw-page-title-main">Illusory palinopsia</span> Subtype of palinopsia

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.

Body image disturbance (BID) is a common symptom in patients with eating disorders and is characterized by an altered perception of one's own body.

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