Anxiety, panic, and hopelessness during and after ritual ayahuasca intake in a woman with generalized anxiety disorder : A case report
Rafael G. DOS SANTOS, Flavia L. OSÓRIO, José Alexandre S. CRIPPA and Jaime E. C. HALLAK
Journal of Psychedelic Studies, 2017, 1, (1), pp. 35–39
Background and aims : Ayahuasca is a dimethyltryptamine- and β-carboline-rich hallucinogenic beverage traditionally used by indigenous groups of Northwest Amazonian for ritual and therapeutic purposes. Animal and human studies suggest that ayahuasca has antidepressant and anxiolytic potentials and has a good safety profile. However, anxiety-like reactions may also occur after ayahuasca intake, although they are rare.
Methods : Case report.
Results : Here, we describe a case of a non-medicated, symptom-free young female with generalized anxiety disorder, who experienced intense anxiety, panic, and hopelessness during and for 3 days after participating in an ayahuasca ritual. The symptoms appeared in the first hours after ayahuasca intake and were gradually reducing in the following hours/days, but were intense enough to cause significant suffering to her, who needed to seek psychiatric help and restarted pharmacological treatment.
Conclusions : Although “bad/horror trips” with anxiety features may occur during the acute effects of ayahuasca and other hallucinogens, to the best of our knowledge, this is the first report of a subacute/ prolonged anxiety-like reaction to this substance. Ayahuasca should be used with caution in people with a history of anxiety disorders.
Keywords : hallucinogens, ayahuasca, dimethyltryptamine, anxiety disorders
Ayahuasca is a botanical hallucinogenic beverage traditionally used by indigenous groups throughout the Northwestern Amazon for ritual and therapeutic purposes (Schultes & Hofmann, 1992). It is usually prepared by the prolonged decoction of the stems of the Banisteriopsis caapi vine combined with the leaves of the Psychotria viridis bush (Schultes & Hofmann, 1992). In the past decades, the use of ayahuasca has spread from South America to the United States, Europe, Africa, and Asia (Labate, Rose, & dos Santos, 2009). Active ingredients in ayahuasca include the tryptamine hallucinogen N,N dimethyltryptamine (DMT) and β-carboline alkaloids, such as harmine, tetrahydroharmine, and harmaline (Schultes & Hofmann, 1992). DMT is as an agonist at cortical 5-HT2A receptors, and the
β-carbolines are reversible inhibitors of monoamine oxidase type A (MAO-A; dos Santos, Balthazar, Bouso, & Hallak, 2016). Pure DMT is not psychoactive after oral administration, but in the case of ayahuasca, reversible inhibition of peripheral MAO-A by the β-carbolines allows DMT to reach systemic circulation and the central nervous system (dos Santos, Balthazar, et al., 2016). Acute ayahuasca administration to healthy volunteers in controlled settings is well tolerated (dos Santos, Balthazar,
et al., 2016). The psychoactive effects of orally administered ayahuasca begin within 30–40 min, peak around 1.5/2 hr, and gradually disappear in 4–6 hr after ingestion, and include perceptual alterations, introspection, and positive mood, although transient increases in psychotic and mania symptoms may also occur (de Araujo et al., 2012; dos Santos, Balthazar, et al., 2016). Nausea and vomiting are the most frequent adverse effects reported (dos Santos, Balthazar, et al., 2016). Dysphoric reactions, such as transient disorientation, anxiety, or suspiciousness/paranoia, are rare and short-lived, and usually respond well to verbal support and disappear completely after the expected time of action of ayahuasca without the need of medical intervention (dos Santos, Balthazar, et al., 2016; Riba & Barbanoj, 2006; Riba et al., 2001). In controlled settings, no prolonged adverse reactions of ayahuasca were ever reported (dos Santos, Balthazar, et al., 2016; Riba & Barbanoj, 2006; Riba et al., 2001). These results are similar to previous studies involving the administration of other hallucinogens that also act as 5-HT2A agonists, such as psilocybin and lysergic acid diethylamide (LSD) (Cohen, 1960; Strassman, 1984; Studerus, Kometer, Hasler, & Vollenweider, 2011). Adverse reactions to these drugs can be classified along a temporalseverity- frequency continuum, from acute, short-lived reactions, involving anxiety, fear, panic, or psychotic symptoms (a “bad trip”), which are the most common adverse reactions and are often fairly benign, to subacute and chronic talked about the therapeutic potentials of ayahuasca, she started reading anecdotal and scientific reports describing anxiolytic effects of ayahuasca and decided to participate in an ayahuasca ritual in a place near her city in Brazil, a country that allows the religious use of ayahuasca (Labate et al., 2009). At the time of the episode, she was obtaining graduate training in a Brazilian university. Ms. A did not provide a detailed description of the ritual setting, such as her impressions of the place, if there were experienced guides to coordinate the ceremony and help in the case of difficult experiences, or if there was some kind of preparation before (and integration after) the ritual. She just described the setting as a place where ayahuasca rituals were performed. The lack of a detailed description of the setting could reflect the fact that this was the first time that Ms. A was ingesting ayahuasca; therefore, she did not have any mark of reference how an appropriate setting and integration would look like. During the ceremony, she ingested two consecutive ayahuasca doses, separated by a 2-hr interval. Unfortunately, given the retrospective nature of the report, it was not possible to perform a chemical analysis in the ayahuasca sample used by Ms. A. Although she did not feel any psychoactive effects with the first dose, after the second dose (the exact time was not reported by her), she began to experience very intense anxiety, panic, and hopelessness, and also arrhythmia: “I was 100 times more
anxious than normal,” “I panicked with the idea of never being able to come back to my normal mental state again,” “I was unable to stop moving around, and the feeling of hopelessness stayed with me for hours, until the end of the ritual,” “I knew that I was not going to die, but the arrhythmia was worrying me so much that I asked one of the ritual organizers if there was any physician present, but there was none.” Ms. A did not report the presence or emergence of complicated and anxiety-provoking psychological material during the episode. Some of the organizers tried to make her calm and comfortable, and she even tried to take a shower in the attempt to reduce her anxiety, but the psychological suffering persisted for the next 8 hr of the ritual. After this period, anxiety symptoms began to reduce their intensity but continued to concern her. Ms. A was able to drive to the hotel where she was staying, and anxiety symptoms continued to reduce their intensity in the following hours. However, Ms. A still felt anxiety and hopelessness for the next 3 days, and resumed her psychiatric treatment when she finally felt better. Currently, Ms. A is using mirtazapine, clonazepam, and zolpidem everyday, and her anxiety and insomnia have improved. Interestingly, despite the adverse psychiatric effects associated with ayahuasca ingestion, Ms. A also attributed some beneficial effects to her experience, such as reductions in alcohol and cannabis use and increase in yoga and meditation practices.