Hallucinogen-persisting Perception Disorder in a 21-year-old Man

Hallucinogen-Induced Persisting Perception Disorder: A Case Report

Hallucinogen-persisting perception disorder (HPPD), also known as acute hallucinogen-induced psychosis or informally known as "flashbacks," is an unusual condition experienced by patients due to the use of different hallucinogenic substances. Hallucinogen-persisting perception disorder causes many symptoms, predominantly persistent visual perception distortion instead of intermittent distortion. Although different hallucinogens could cause HPPD, lysergic acid diethylamide (LSD) and LSD-like properties seem to be the most common hallucinogens causing the symptoms. In our case report, the patient is a 28-year-old Caucasian male with a long psychiatric and social history of polysubstance use using LSD and cannabis. He started experiencing many of the classic symptoms of HPPD seven months after stopping LSD. The diagnosis is suspected by ruling out all other possible underlying causes with the help of several laboratory and imaging tests. Despite having an extensive psychiatric history of illnesses, the patient's symptoms failed to improve with antipsychotics, confirming that the symptoms were not only due to mental illness. Although supposedly the first-line treatment for HPPD is the use of alpha-2 adrenergic drugs such as clonidine and benzodiazepines, we started to witness improvement in patient's symptoms with the use of lamotrigine, which is the gold standard in treating perceptual disturbance in time and space.

Hallucinogenic Persisting Perception Disorder: A Case Series and Review of the Literature

Background

Hallucinogen persisting perception disorder (HPPD) is characterized by the re-emergence of perceptual symptoms experienced during acute hallucinogen intoxication following drug cessation. The underlying pathophysiology is poorly understood. We report the clinical characteristics and investigation findings of a series of HPPD cases with a literature review of previous case reports. We draw parallels between the features of HPPD and Visual Snow Syndrome (VSS).

Methods

Retrospective case series of 13 patients referred from neuro-ophthalmologists. Literature review with 24 HPPD case reports were identified through database search using the terms “hallucinogenic persisting perception disorder” OR “hallucinogen persisting perception disorder.”

Results

Lysergic acid diethylamide (LSD), 3,4-Methyl enedioxy methamphetamine (MDMA) and cannabinoid use was common. Cannabinoids and MDMA were mostly used in association with classical hallucinogens. The most frequent symptoms in our patients were visual snow, floaters, palinopsia, photophobia and nyctalopia. In the literature other symptoms included visual hallucinations altered motion perception, palinopsia, tracers and color enhancement. Ophthalmic and neurologic investigations were mostly normal. The majority of patients had ongoing symptoms. Two of our patients fully recovered—one after treatment with benzodiazepine and one without treatment. Twenty-five percent of cases from the literature fully recovered.

Conclusions

HPPD presents with heterogeneous visual phenomena on a background of previous classic and non-classic hallucinogen use. Ophthalmic investigations are typically normal. The symptoms of HPPD in our case series overlap with the typical features of Visual Snow Syndrome (VSS). Patients presenting with VSS should be screened for past recreational drug use. The DSM-5 description of HPPD does not include visual snow, nyctalopia, photophobia or floaters. A revision of the diagnostic criteria to include these symptoms may better reflect the typical clinical phenotype. Increased awareness of HPPD as a secondary cause of VSS can avoid extensive investigations. Controlled trials comparing primary and secondary VSS patients are needed to understand the pathophysiology better and optimize treatment for HPPD.

Hallucinogen persisting perception disorder: A literature review and three case reports

The paper describes diagnostic criteria, clinical presentation and types of hallucinogen persisting perception disorder (HPPD), as well as current approaches to the treatment of this phenomenon using available scientific sources. Three case reports are also presented to demonstrate different types of this disorder. The first case report describes a 23-year old patient with a previous history of cannabis consumption who reported HPDD type I after the use of psilocybin mushrooms with small amounts of alcohol and hash. A month later, after cannabis use, the same visual and auditory distortions appeared again. During the following year, hallucinations recurred with the consumption of natural cannabinoids but not with alcohol intake. The symptoms have reduced within a year. Surprisingly, both other cases belonging to HPDD type II appeared in patients who consumed ecstasy, although MDMA is generally not considered a hallucinogen and hallucinations are not frequently reported after MDMA consumption. In both cases of HPPD type II after the use of ecstasy, the condition was very stressful and frightening. Both patients sought medical help and received tofisopam, lamotrigine and sertraline. After that, in both cases visual impairments have smoothed, but have not passed completely. Scientific sources suggest that HPPD may affect more than 50% of hallucinogen users and this disorder is often underdiagnosed. Therefore, patients suffering from HPPD can present in various clinical settings, and clinicians should be aware of this condition.