ANALYSIS AND COMMENTARY The Psychedelic Renaissance and Its Forensic Implications Brian Holoyda, MD, MPH, MBA Recent years have seen a renaissance of research into the use of psychedelic compounds to address various psychiatric conditions. The study of these substances went dormant in 1970 when the United States government passed the Controlled Substances Act, which categorized lysergic acid diethylamide, commonly known as LSD or acid, as a Schedule I drug. The rise of psychedelics in research settings raises questions regarding their risks outside of clinical trials. The available data on the impact of psychedelic use on interpersonal violence and other criminal behavior remain scant. Although Timothy Leary’s work of the 1960s failed to clearly demonstrate a reduction in criminal recidivism with psychedelic-assisted psychotherapy, recent studies suggest that the use of psychedelics may reduce individuals’ risk of interpersonal violence. Forensic psychiatrists should be aware of this research, as well as the role that psychedelics may play in various forensic assessments. This article summarizes basic information that the forensic practitioner should know about psychedelic substances, including their various effects and proposed mechanism of action; describes historical and recent research into psychedelics and criminal behavior; and offers evaluators a practical means by which to assess individuals’ psychedelic use in forensic contexts. J Am Acad Psychiatry Law 48:87–97, 2020. DOI:10.29158/JAAPL.003917-20 Psychiatrist Humphry Osmond first introduced the Hell or soar angelic/Just take a pinch of psyche- term “psychedelic” to the scientific community delic” (Ref. 2, p 713). when he spoke of his research on the compound Various investigators studied the therapeutic po- lysergic acid diethylamide (LSD) at a 1957 meeting tential of LSD and other psychedelic compounds un- of the New York Academy of Sciences.1 Osmond had til the 1960s. At that time, individual states began to been studying the effects of LSD on patients with ban the production and distribution of LSD. The various psychiatric maladies since 1952 as the deputy federal government’s categorization of LSD as a director of psychiatry at the Saskatchewan Mental Schedule I substance under the Controlled Sub- Hospital. He found that LSD fundamentally altered stances Act of 1970 caused clinical research on psy- patients’ cognition: it could disrupt logical thought, chedelics to come to a standstill.3 Like cannabinoids, distort perception of reality, and alter consciousness. methylenedioxymethamphetamine (MDMA), ket- He purposefully selected the term psychedelic, de- amine, and other psychoactive substances, however, rived from the Greek psyche (i.e., the mind or soul) psychedelics are once again seeing their day in clinical and delos (i.e., to show). Psychedelic referred to the research trials for conditions ranging from addiction 4 “mind-manifesting” capabilities of LSD and similar to anxiety related to terminal illness. Mainstream compounds. Osmond famously stated, regarding journalist Michael Pollan’s latest book, How to his newly defined substance category, “To fathom Change Your Mind, has shined a public spotlight on this class of chemicals’ effects and therapeutic poten- 5 Published online January 16, 2020. tial. In May 2019 Denver become the first jurisdic- Dr. Holoyda is a Forensic Psychiatrist, Las Vegas, NV. Address corre- tion of the United States to decriminalize mush- spondence to: [email protected]. rooms containing psilocybin.6 There has been a Disclosures of financial or other potential conflicts of interest: None. comparative silence regarding the forensic implica- Volume 48, Number 1, 2020 87 The Psychedelic Renaissance and Its Forensic Implications Table 1 Names and Sources of Common Classic Psychedelics Chemical Name Common or Slang Name Natural Sources 5-Methoxy-N,N-dimethyltryptamine 5-MeO-DMT, the toad Yopo tree (Anadenanthera peregrina) seeds, skin exudate from the Sonoran desert toad (Bufo alvarius) Lysergic acid diethylamide LSD, acid Synthetically derived from ergot fungus (Claviceps purpurea) N,N-dimethyltryptamine DMT, the spirit molecule Chacruna shrub (Psychotria viridis) and other plant species Mescaline Peyote Peyote cactus (Lophophora williamsii), San Pedro cactus (Echinopsis pachanoii), Peruvian torch cactus (Echinopsis peruviana) Psilocybin Mushrooms, magic mushrooms, shrooms Psilocybe mushroom species From Reference 7. tions of the psychedelic renaissance. Questions re- tered somatosensory, visual, auditory, and proprio- garding psychedelic use and interpersonal violence ceptive perception; synesthesia; derealization; and and other forms of criminal behavior remain largely depersonalization.9 The effects of psychedelics are unanswered, though new research is beginning to not clearly dose-dependent, but higher doses may be provide some evidence to better elucidate the rela- associated with qualitatively different phenomena re- tionship. With increasing public interest in psyche- sulting from completely altered consciousness. Users delics, forensic psychiatrists may be increasingly may lose awareness of their environment and their likely to encounter subjects with a history of use and perception of time and space. Some users report mys- will require a framework to assess the use of this tical or transcendent experiences, such as being one unique category of compounds. This article summa- with the universe, reliving memories, encountering rizes basic information regarding psychedelics that otherworldly or god-like beings, or facing one’s own forensic psychiatrists should know; describes and as- death.9 sesses available research regarding the relationship Other types of psychoactive substances may be between psychedelics, criminal behavior, and inter- grouped with the classic psychedelics depending on personal violence; and delineates practical recom- the context or due to overlapping effects. For exam- mendations for forensic evaluators examining indi- ple, empathogens or entactogens are chemicals that viduals with a history of psychedelic use. produce euphoria and a sense of emotional connect- edness and openness to others. Examples include A Psychedelic Primer MDMA (also known as ecstasy) and 4-methyl meth- Psychedelics are a unique category of psychoactive cathinone (also known as mephedrone or “bath substances. Though some psychedelics like LSD are salts”). These compounds primarily work via mono- synthesized exclusively in the laboratory, others can amine reuptake inhibition and release.10 Another be derived from natural sources, including plants, notable difference between the classic psychedelics fungi, and the secretions of animals. Table 1 summa- and empathogens is that psychedelic substances do rizes the chemical name, common names, and natu- not generate symptoms commonly associated with ral sources of some of the most well-characterized drug dependence, such as withdrawal or craving, psychedelic substances. Classic psychedelic com- whereas empathogens may.11,12 Ketamine and phen- pounds exert their effects through agonism of the cyclidine (PCP) are also compounds with which psy- 5-HT2A receptor in pyramidal neurons.7 Neuro- chedelics may be grouped, though they exert their physiologic effects include alteration of cerebral dissociative effects via inhibition of the N-methyl-D- blood flow and metabolism, increased connectivity aspartate glutamate receptor. Effects of ketamine and between brain regions that typically do not commu- PCP may include feelings of euphoria, sedation, hal- nicate, and decreased activation of and communica- lucinations, and distortion of time and space.13 Sim- tion between nodes of the default mode network, a ilar to psychedelics, researchers are identifying an neural system thought to play a role in introspec- increasing number of psychotherapeutic uses of both tion.8 Psychedelic effects are varied and include al- MDMA and ketamine. 88 The Journal of the American Academy of Psychiatry and the Law Holoyda DSM-5 and Psychedelics Criminal Behavior and Violence The Diagnostic and Statistical Manual of Mental With the revival of interest in the therapeutic po- Disorders, 5th Edition (DSM-5),14 does not utilize tential of LSD, psilocybin, and other compounds, it the term “psychedelic,” instead putting psychedelics is increasingly important to understand the forensic and MDMA in the category of other hallucinogens. implications of their use. Of concern is the relation- Use of the term “hallucinogen” has largely fallen out ship between psychedelic use and violence and other of favor among modern researchers when describing criminal behavior. The literature examining the rela- psychedelics because the compounds typically do not tionship between psychedelics and violence largely cause users to experience frank hallucinations, and consists of case reports, though there are an increas- ing number of epidemiological survey studies exam- the characterization fails to capture the range of other ining this relationship. I conducted a search of effects that psychedelics can have on an individual’s 15 PubMed and PsychINFO databases to identify pub- consciousness. The DSM-5 also provides for diag- lished articles on psychedelic use and violence. A noses of other hallucinogen intoxication, other hal- PubMed search of [psychedelics, hallucinogens, ly- lucinogen intoxication delirium, hallucinogen per- sergic acid diethylamide, or psilocybin] and [vio- sisting perception disorder (HPPD), as well as other lence, homicide,