Isr J Psychiatry Relat Sci - Vol 48 - No.1 (2011) ARTURO G. LERNER ET AL. Benign and Time-Limited Visual Disturbances (Flashbacks) in Recent Abstinent High-Potency Heavy Cannabis Smokers: A Case Series Study Arturo G. Lerner, MD,1,2 ,Craig Goodman, PhD, 1 Dmitri Rudinski, MD, 1 and Avi Bleich, MD1, 2 1 Lev Hasharon Mental Health Medical Center, Pardessya, Israel 2 Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel may induce a state of intoxication popularly referred ABSTRACT to as a “trip” (4). These “trips” or substance-induced experiences are generally transient and reversible states Eight high-potency heavy cannabis smokers who that are typically accompanied by perceptual distur- fulfilled DSM-IV-TR criteria for cannabis dependence bances. The mind-altering effects are experienced in sought treatment for outpatient detoxification. a clear sensory-conscious state, while awake and alert During routine psychiatric interview they reported the and generally in the absence of confusion (5-8). A well presence of visual disturbances when intoxicated and known, unique and intriguing side effect associated no prior history of LSD use. They all communicated with the use of synthetic hallucinogens such as lysergic the persistence of visual disturbances after ceasing acid diethylamide-LSD and LSD-like substances is the cannabis use. Seven categories of visual disturbances partial or total recurrence of the perceptual disturbances were described when staring at stationary and moving which previously appeared during intoxication, in the objects: visual distortions, distorted perception of absence of recent use (9-11). These experiences are distance, illusions of movement of stationary and accompanied by full insight and can be short or long- moving objects, color intensification of objects, term (10, 11). The original intoxicating experience may dimmed color, dimensional distortion and blending be “good” (pleasant) or “bad” (unpleasant). In the same of patterns and objects. Patients reported having 2-5 way, the perceptual recurrences recapitulate the prior different categories of flashbacks up to 3-6 months “trip” or intoxication that was experienced as either after cessation of cannabis use. The described “good” or “bad.” A previous “good” trip, however, does phenomena may be interpreted as a time-limited not always predict or ensure a “good” recurrence (10, benign side effect of high-potency cannabis use in 11). Common recurrent visual disturbances attributed some individuals. A combination of vulnerability and to this complex syndrome are geometric hallucina- use of large amounts of high–potency cannabis seem tions, false perception of movement in the peripheral to contribute to the appearance of this condition. visual fields, flashes of colors, intensified colors, trails Conclusions from uncontrolled case series should be of images of moving objects, positive afterimages, halos taken with appropriate caution. around objects, macropsia and micropsia (12). At least two subtypes of this syndrome have been reported. The first is flashback. It is a short term, tran- sient, recurrent, spontaneous, reversible and generally visual benign experience. Experienced LSD users gener- INTRODUctiON ally look at these recurrences as a “free trip,” an aspect Hallucinogens encompass a group of naturally-occur- of the psychedelic dimension, and do not seek psychiat- ring substances from vegetable (1) and animal (2) ric assistance after experiencing these types of episodes. origins as well as synthetic chemical agents (3) which Certain individuals may experience the recurrence of Address for Correspondence: Arturo G. Lerner, MD, Lev Hasharon Mental Health Medical Center, POB 90000, Netanya 42100, Israel [email protected] ; [email protected] 25 BENIGN AND TIMe-LIMITED VISUAL DISTURBANCES (FlashbacKS) IN RECENT ABSTINENT HIGH-PoTENCY the same single flashback while other perhaps more attempted to stop cannabis use in the past without suggestible subjects may have a variety of them. The professional assistance. Patients included in the report second is hallucinogen persisting perception disorder met the DSM-IV-TR criteria for cannabis dependence (HPPD). This is long-term, spontaneous, intermittent (12). They reported the need for markedly increased or continuous, pervasive and either slowly reversible amounts of cannabis to achieve desired effect, cannabis or irreversible. This disorder is entirely different from was smoked over longer periods than was intended, the benign flashback (10, 11). HPPD is a condition in there were unsuccessful efforts to stop or control its which the re-experiencing of one or more perceptual use, a great deal of time was spent to obtain cannabis symptoms causes significant distress or impairment in and finally social, occupational and recreational activi- social, occupational or other important areas of func- ties were impaired (12).They communicated cannabis tioning (12). HPPD often occurs in individuals with no intoxication with perceptual disturbances (12), the prior psychopathology, and may be extremely debili- intake of high concentrated cannabis (22) since start- tating. Hallucinogen users are usually aware of these ing cannabis use, a smoking period of at least five years severe, intruding and disabling consequences of LSD and a daily consumption (“joints” and water pipes) of consumption and generally actively seek psychiatric at least three times a day (i.e., morning, noon or after- help. HPPD seems to be part of a large spectrum of noon and evening). They had no prior use of LSD or non-psychopathological and psychopathological expe- other hallucinogenic substances. All patients had pre- riences reported by hallucinogen users (10, 11). vious compulsory military service, no prior police or Whether or not the use of cannabis alone can be asso- criminal records, and were not married. Four of the ciated with persisting perceptual abnormalities has been patients reported smoking cannabis alone. The other debated. Investigators tend to agree that cannabis can four reported occasional use of cocaine, MDMA, and precipitate perceptual recurrences in subjects who had also fulfilled full criteria for nicotine dependence (12). previously used LSD and that it is unlikely that canna- Visual disturbances during intoxication were reported bis alone can provoke recurrent perceptual disturbances only after being interviewed for treatment and were not (13-15). However, there are reports of depersonalization accurately recalled. Treatment was not sought due to (16, 17), perceptual symptoms experienced during can- visual disturbances. They associated the precipitation nabis intoxication (18, 19) and short-term spontaneous of visual disturbances only and strictly by cannabis recurrent visual disturbances (20) after the suspension smoking. Other consumed legal (nicotine and alco- of cannabis use alone. Reliability of recurrent canna- hol) and illegal (ecstasy and cocaine) substances were bis associated visual experiences has been critically not associated with the perceptual disturbances. None questioned. It should be noted that according to DSM- of the patients had any co-morbid medical disease or IV-TR the diagnostic criteria of cannabis intoxication co-occurring psychiatric disorders. Neurological and allows for a diagnosis of “with perceptual disturbances” ophthalmologic examinations were intact. Two patients (12). If perceptual disturbances can be observed dur- had a family history of schizophrenia. ing intoxication by cannabis alone (12, 21), it is plau- sible that some predisposed and susceptible cannabis DEMOGRAPHIC Data heavy smokers using high concentrated cannabis (22) Mean age of patients was 29.25 years old (S.D.=2.25), may partially or totally recapitulate the previous per- mean education was 13.13 years (S.D.=1.55), mean ceptual experience in the absence of present cannabis duration of non-use was 82.25 days (S.D.=40.6), mean use. We present the cases of eight high-potency heavy duration of cannabis use was seven years (S.D.=1.69), users of cannabis without a prior history of LSD use and mean number of previous attempts of cessation or who reported the presence of benign persisting visual detoxifications was 0.625 (S.D.=0.74). All patients were disturbances after stopping cannabis consumption. white males of Jewish Israeli descent, were currently employed, and had a middle class socioeconomic status. METHOD DETOXIFicatiON AND FOLLow-up CLINicaL Data Tetrahydrocannabinol (THC) was present in urine Eight patients were examined after seeking treatment samples prior to initiation of detoxification. No other for cessation of chronic cannabis use. Four of them psychoactive substances were identified. All patients 26 ARTURO G. LERNER ET AL. underwent uncomplicated outpatient cannabis detoxi- when staring at stationary and moving objects: visual fication using only minimal symptomatic medication distortion (slightly blurred object), distorted perception like small doses of clonidine (23) and careful use of of distance (objects were slightly seen closer or distant), benzodiazepines. They continued working when under- illusion of movement of stationary and moving objects going treatment reflecting low severity or control of the (slow movement), color intensification of objects (slightly detoxification process. After detoxification and follow- more intensified), dimmed color (slightly less intensified), up, substances of abuse were not identified in random dimensional distortion (objects were slightly