Comments & Controversies

Hallucinogen sequelae Common visual disturbances attributed I appreciated “The woman who saw the to HPPD are recurrent geometric halluci- light” (C!""#$% P&'()*+%"', July 2010, nations, perception of peripheral move- p. 44-48) in which Dr. R. Andrew ment, colored "ashes, intensi#ed colors, Sewell et al describe a 30-year-old palinopsia, positive afterimages, haloes woman with schizoaffective disorder around objects, macropsia, and micropsia and a 7-year history of visual distur- occurring spontaneously in individuals bances, including “,ashing lights.” with no prior psychopathology. These dis- The authors’ differential diagnosis did turbances can be intermittent or continu- not include the possibility of visual ous, slowly reversible or irreversible, but disturbance secondary to atypical anti- are severe, intrusive, and cause functional psychotic serotonergic antagonism. debility. Su!erers retain insight that these Photopsia and similar phenomena are phenomena are the consequence of LSD not uncommon with 5HT antagonist use and usually seek psychiatric help. 1 antidepressants, such as nefazodone. July 2010 HPPD may be diagnosed by the pres- They also are well-known sequelae ence of an identi#able trigger, prodromal of lysergic acid diethylamide (LSD), a symptoms, and presentation onset; by the VA: American Psychiatric Publishing, Inc.; 2007. complex serotonin antagonist/agonist, 2. Kranzler H, Ciraulo D. Clinical manual of addiction characteristics of the perceptual distur- psychopharmacology. Arlington, VA: American and would be included under the Psychiatric Publishing, Inc.; 2005. bances, their frequency, duration, intensi- DSM-IV-TR diagnosis hallucino- 3. Halpern JH, Pope HG Jr. Hallucinogen persisting ty, and course; and by the accompanying perception disorder: what do we know after 50 2 gen persisting perceptual disorder years? Drug Alcohol Depend. 2003;69:109-119. negative a!ect and preserved insight. (HPPD).2 Risperidone, a 5HT2-block- 4. Abraham HD, Mamen A. LSD-like panic from This LSD-induced persistence of visual risperidone in post-LSD visual disorder. J Clin ing atypical, and selective serotonin Psychopharmacol. 1996;16(3):238-241. imagery after the image is removed from reuptake inhibitors may worsen HPPD 5. Lauterbach EC, Abdelhamid A, Annandale JB. the visual #eld is thought to result from Posthallucinogen-like visual illusions (palinopsia) effects.3,4 Visual disturbance with ris- with risperidone in a patient without previous dysfunction of serotonergic cortical inhibi- hallucinogen exposure: possible relation to serotonin peridone also has been reported in a 5HT2a receptor blockade. Pharmacopsychiatry. tory interneurons with GABAergic outputs 2000;33(1):38-41. patient with no LSD exposure.5 Dr. that normally suppress visual processors.3 Sewell’s patient was treated sequential- Clonazepam often is helpful.2 ly with aripiprazole and olanzapine. The authors respond R. Andrew Sewell, MD Both have 5HT blocking properties. We agree with Dr. Krasnow that HPPD be- VA Connecticut Healthcare/Yale University School of Medicine I wonder if the patient has a history longs within our di!erential diagnosis for New Haven, CT of hallucinogen or LSD exposure, or photopsia and regret omitting it from our David Kozin whether her visual symptoms might article. We consider this to be unlikely, how- McLean Hospital/Harvard Medical School be related to the use of atypical anti- ever, because she had no prior LSD use, a Belmont, MA psychotics combined with sertraline. history of well-formed visual hallucinations Miles G. Cunningham, MD, PhD McLean Hospital/Harvard Medical School It would be interesting to see if her not characteristic of HPPD, and no other Belmont, MA symptoms abated with use of a -rst- characteristic symptoms of HPPD (palinop- generation antipsychotic. sia, afterimages, illusory movement, etc.). References 1. Espiard ML, Lecardeur L, Abadie P, et al. Charles Krasnow, MD In addition, she tolerated olanzapine Hallucinogen persisting perception disorder Adjunct clinical assistant professor of well, and there is anecdotal evidence and after psilocybin consumption: a case study. Eur psychiatry Psychiatry. 2005;20:458-460. 1 case report to suggest that olanzapine 2. Lerner AG, Gelkopf M, Skladman I, et al. University of Michigan Medical School Clonazepam treatment of lysergic acid Ann Arbor, MI exacerbates HPPD.1 diethylamide-induced hallucinogen persisting perception disorder with anxiety features. Int HPPD typically is considered a rare Clin Psychopharmacol. 2003;18:101-105. References sequela of LSD use, although even more 3. Abraham HD, Aldridge AM. Adverse 1. Schatzberg A, Cole J, DeBattista DMH. Manual of consequences of lysergic acid diethylamide. clinical psychopharmacology. 6th ed. Arlington, rarely it may be caused by other drugs. Addiction. 1993;88:1327-1334.

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