Hallucinogen-persisting perception disorder, Leo Hermle et al., 2012

Hallucinogen-persisting perception disorder

Leo Hermle, Melanie Simon, Martin Ruchsow and Martin Geppert

Therapeutic Advances in Psychopharmacology, 2012, 2, (5), 199–205

DOI: 10.1177/2045125312451270


Abstract :

A 33-year-old female patient developed a hallucinogen-persisting perception disorder (HPPD) after lysergic acid diethylamide (LSD) abuse for a year at the age of 18. Specifically, she reported after images, perception of movement in her peripheral visual fields, blurring of small patterns, halo effects, and macro- and micropsia. Previous treatment with antidepressants and risperidone failed to ameliorate these symptoms. Upon commencing drug therapy with lamotrigine, these complex visual disturbances receded almost completely. Based on its hypothesized neuroprotective and mood-stabilizing effects, the antiepileptic lamotrigine may offer a promising new approach in the treatment of HPPD.

Keywords : Flashback, hallucinogen-persisting perception disorder, LSD



The complex phenomenology of acute hallucinogen- induced psychosis has been described and analysed extensively over the years. However, the clinical relevance of the long-term psychological sequelae which include so-called flashbacks remains unclear [Hermle et al. 1992; Hermle et al. 2008]. Moreover, a consistent etiological model to explain these effects has yet to be proposed. Ever since the first description [Cooper, 1955], reports about the incidence of post-toxic flashbacks show a wide variation. Between 5% and 50% of hallucinogen users are reported to have experienced at least one flashback [Alarcon et al. 1982; McGee, 1984].

Flashbacks, echo phenomena and other psychotic manifestations typically occur after drug-free periods of varying lengths. In the International Classification of Diseases, 10th revision (ICD- 10), such hallucinogen-induced echo psychoses are listed under F16.70 [Dilling et al. 1991; Pechnik and Ungerleider, 2004]. However, the Diagnostic and Statistical Manual of Mental Disorders, fourth revised edition (DSM-IV-R) [American Psychiatric Association, 1994], classifies these phenomena under the term ‘hallucinogen persisting perception disorder (HPPD)’ – defined as a long-lasting condition characterized by spontaneous recurrence of visual disturbances reminiscent of acute hallucinogen intoxication. Such experiences may take the form of various geometric shapes, objects in the peripheral visual fields, flashes of different colours, enhanced colour intensity, trailing and stroboscopic perception of moving objects, after images, halos and macro- and micropsia. Furthermore, these episodes may persist for years. At variance with DSM-IV-R, ICD-10 recognizes hallucinogeninduced visual disturbances as lasting only seconds to minutes.

It is important to note that in contrast to classical psychotic disorders, patients with HPPD recognize the unreal nature of their visual disturbances which qualifies them as pseudo-hallucinations.