726694

research-article2017
APY0010.1177/1039856217726694Australasian PsychiatryAnderson et al.

Australasian
Case Report Psychiatry
Australasian Psychiatry

The trip of a lifetime: hallucinogen 1­–2

© The Royal Australian and
New Zealand College of Psychiatrists 2017

persisting perceptual disorder Reprints and permissions:

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DOI: 10.1177/1039856217726694
https://doi.org/10.1177/1039856217726694
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Lauren Anderson  Medical Officer, Royal Melbourne Hospital, Department of Psychiatry, Parkville, VIC, Australia
Hannah Lake  Psychiatrist Royal Melbourne Hospital, Department of Psychiatry, Parkville, VIC, Australia
Mark Walterfang  Neuropsychiatrist Royal Melbourne Hospital, Department of Neuropsychiatry, Parkville, VIC, Australia

Abstract
Objectives: The differential diagnosis of psychotic symptoms is broad and extends beyond primary psychotic and
affective disorders. We aim to illustrate that the chronology and phenomenological nature of hallucinatory symp-
toms may provide clues towards alternative diagnoses, such as hallucinogen persisting perceptual disorder (HPPD).
We describe the resurgence of visual pseudo-hallucinations in a young woman in the context of previous substance-
induced hallucinatory symptoms and a prior diagnosis of occipital lobe epilepsy. She presented a diagnostic challenge,
saw several emergency and specialist doctors and attracted stigmatising diagnoses leading to anxiety and depressive
symptoms. Her symptoms were finally recognised as HPPD, and she was treated appropriately with lamotrigine.
Conclusions: Patients with perceptual disturbance can present in various clinical settings, and HPPD is an under-rec-
ognised diagnostic possibility. Delayed or misdiagnosis prolongs profound functional impairment and social decline,
and predisposes the patient to the development of anxiety and depression and related increased risk of suicide.

Keywords:  HPPD, hallucinogen persisting perceptual disorder, hallucinogen, visual hallucination

T
he differential diagnosis of psychotic symptoms demonstrating bilateral occipitotemporal epileptiform
is broad and extends beyond primary psychotic discharges. She was subsequently commenced on levati-
and affective disorders. The chronology and phe- racetam, which was ceased three days later due to worsen-
nomenological nature of hallucinatory symptoms may ing of symptoms. She did not follow-up with mental-health
provide clues towards alternative diagnoses. We describe services or neurology thereafter. Her distressing symp-
the onset of psychotic symptoms in a young woman in toms persisted for 18 months, despite refraining from rec-
the context of previous substance-induced hallucinatory reational drug use, leading to depressive symptoms, severe
symptoms. anxiety and relationship breakdown. Her perceptual dis-
turbances began to improve two months after commence-
ment on lamotrigine 50 mg daily by a general practitioner,
Clinical history in light of her putative diagnosis of occipital epilepsy. She
A 27-year-old female postgraduate student with previous remained symptom free for three years, finished an
diagnoses of occipital lobe epilepsy and schizophrenia undergraduate degree, relocated to study medicine and
presented with a recurrence of prolonged and distressing had significant sporting achievements.
multimodal pseudo-hallucinations, despite abstinence The recurrence of symptoms occurred spontaneously one
from recreational drug use. night while out with friends. She described symptoms
Her first contact with mental-health services occurred at comparable to ‘being stuck on a bad trip’, with distortion
the age of 22 years, when she presented following a week- and misinterpretation of existing objects in space (e.g.
end poly-substance binge, including MDMA (‘ecstasy’), her arm seeming three times as long, and specks of dust
other amphetamines and marijuana, waking one day on the ground appeared abnormally obvious), the false
with complex multimodal visual hallucinations and dis- perception of movement in peripheral visual fields, halos
tortions. She attracted diagnoses of drug-induced psycho-
sis and schizophrenia. She was unsuccessfully treated for
three months with risperidone, which r­ eportedly Corresponding author:
­exacerbated her symptoms. Six months later, she received Lauren Anderson, Royal Melbourne Hospital, 300 Grattan St,
a tentative diagnosis of occipital lobe epilepsy by a neu- Parkville, VIC 3001 Australia.
rologist following repeat electroencephalograms (EEGs) Email: Lauren.anderson2208@gmail.com

1
 Australasian Psychiatry 00(0)

around objects, intensified lights, after-images, deperson- existing mental disorders such as anxiety, mood and sleep
alisation and derealisation. She described heightened disturbance, entering a dark environment, pregnancy and
senses of hearing, taste and touch whilst having a blunted post-partum states, flashing car or neon lights, exposure
pain threshold. These experiences were intensified by to noise, and exercise.3
higher levels of stimulation, such that she reported that
According to unpublished data referred to in a clinical
exposure to a television screen was intolerable.
review by Lerner et al.,3 some patients show benefit from
No acute trigger was identified. She had two alcoholic various SSRIs, low-dose olanzapine, quetiapine, amisul-
drinks and denied intentional drug use. The onset coin- pride, aripiprazole and asenapine, and antiepileptic
cided with a period of heightened workload at university agents such as valproic acid, carbamazepine, oxycarba-
and reduced sleep. She maintained full insight into her mazepine, gabapentin, topiramate or levetiracetam.
symptoms. She did not exhibit psychotic symptoms. Lamotrigine has been reported as useful, likely by inhibit-
However, she reported a lowered mood and heightened ing the glutamate-mediated excitatory neurotransmission
anxiety as a result of her distressing experiences. The symp- thought to be involved in the pathophysiology of HPPD.4
toms interfered with her functioning, as she was unable to
At one point, a diagnosis of occipital lobe epilepsy was
tolerate high levels of stimulus or navigate traffic.
considered following two abnormal EEGs, suggestive but
Following her relapse in hallucinations, the patient not diagnostic of occipital lobe epilepsy in conjunction
sought help through several emergency departments. with a raft of symptoms, some of which are consistent
Following a brief psychiatric admission, she was reviewed with occipital seizures. An electrophysiology study by
in general adult psychiatry outpatients, prompting a Abraham and Duffy5 demonstrated that HPPD patients
range of investigations. Basic blood tests, neurological exhibit isolated occipital disinhibition and regional
exam, magnetic resonance imaging, EEG and neuropsy- coherence upon eye closure, a state known to facilitate
chiatric and visual testing were normal. Files from her hallucinatory experiences, with similarities to inter-ictal
initial episode were reviewed, and a unifying diagnosis and ictal epileptic foci.
of hallucinogen persisting perceptual disorder (HPPD)
was made. Lamotrigine was increased to 100 mg daily.
Her symptoms improved after two weeks and were Implications for clinical practice
resolved over a period of three months.
Patients with perceptual disturbance can present in vari-
ous clinical settings, and HPPD is an under-recognised
diagnostic possibility. Delayed or misdiagnosis prolongs
Discussion profound functional impairment and social decline, and
Since it was first described by Eisner and Cohen1 in 1964, predisposes the patient to the development of anxiety
the phenomenology of HPPD remains poorly understood, and depression and related increased risk of suicide.
and the literature is limited to case reports and observa-
Studies are needed to understand further the pathophysiol-
tional studies. Incidence is unknown. According to the
ogy of HPPD and its associations with occipital lobe epi-
DSM 5,2 HPPD is characterised mainly by perceptual dis-
lepsy, and to evaluate the efficacy of medications in order to
turbances, taking the following shapes or forms: geomet-
recognise and treat this condition appropriately.
ric hallucinations, false perceptions of movement in the
peripheral field images, flashes of colour, intensified col-
ours, trails of images of moving objects, positive afterim- Disclosure
ages, halos around objects, macropsia and micropsia. In The authors report no conflict of interest. The authors alone are responsible for the content
contrast to psychosis, there is no paranoid misinterpreta- and writing of the paper.
tion of these abnormal perceptions in HPPD sufferers, and
full insight is maintained before, during and after the epi- Funding
sode. Lerner3 has more recently further distinguished The authors received no financial support for the research, authorship, and/or publication of
HPPD-II from HPPD-I (a non-distressing, benign ‘flash- this article.
back’ or ‘free trip’) as a chronic, recurrent, trigger-precipi-
tated or spontaneous, slowly reversible or irreversible, and
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