(PO-046) (PO-046) To treat or not to treat? High-potency benzodiazepine use in a case of comorbid Hallucinogen Persisting Perception Disorder and Alcohol Use Disorder

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Introduction: Hallucinogen Persisting Perception Disorder (HPPD) is characterized by visual disturbances that resemble acute psychedelic intoxication and linger after use has ceased. The most common substances precipitating HPPD, lysergic acid diethylamide (LSD) and psilocybin, are posited to do so via damage to serotonergic neurons involved in vision. Severe and persistent psychedelic re-experiencing occurs in an estimated 2 percent of people with histories of regular hallucinogen use (McGlothlin et al. 1971). Treatment consists of agents that modulate the damaged serotonergic neurons through GABA receptors, with the greatest evidence base for benzodiazepines (Halpern et al. 2018). We present a patient who posed a diagnostic challenge and treatment dilemma. Diagnostically, his symptoms had long been misinterpreted as a primary psychotic disorder, treated for years with antipsychotics. Upon clarifying that HPPD was his actual diagnosis, his substance use disorder raised concerns regarding the appropriateness of benzodiazepine treatment.

Case Summary: Mr. N is a 37-year-old with a history of alcohol, cannabis, LSD, cocaine, and nicotine use disorders who described visual distortions that resolved when he drank heavily or received benzodiazepines for withdrawal. He did not appear psychotic. Although two decades had passed since his last LSD use, he continued to experience illusions of halos around objects, moving walls, and figures appearing cartoonish. He understood that his perceptual disturbances were not reality-based. During hospitalization for suicidal ideation, laboratory tests, head CT, and EEG studies offered no other explanation for his visual disturbances than HPPD. The visual distortions remitted with scheduled clonazepam treatment, although chemical dependency treatment programs were hesitant to accept him while on a benzodiazepine.

Discussion: This case emphasizes the importance of diagnostic clarification when patients present with perceptual disturbances that do not fit typical psychotic presentations. This case exemplifies both the rare entity of HPPD and the treatment conundrum faced when the sufferer also has active substance use disorders. Our discussion will distinguish misperceptions from actual hallucinations and review the pathophysiology of HPPD. Lastly, we will discuss management strategies for patients with co-occurring HPPD and substance use disorders.

Conclusion: It is necessary to discern the correct cause of visual disturbances in order to provide proper treatment. The risks and benefits of long-term benzodiazepine use must be carefully weighed when deciding whether to prescribe them for patients with comorbid HPPD and alcohol use disorder.

References:

Halpern JH, Lerner AG, Passie T. A Review of Hallucinogen Persisting Perception Disorder (HPPD) and an Exploratory Study of Subjects Claiming Symptoms of HPPD. Curr Top Behav Neurosci. 2018;36:333-360. doi: 10.1007/7854_2016_457. PMID: 27822679.

McGlothlin WH, Arnold DO. LSD revisited. A ten-year follow-up of medical LSD use. Arch Gen Psychiatry. 1971 Jan;24(1):35-49. doi: 10.1001/archpsyc.1971.01750070037005. PMID: 5538851.

Learning Objectives:
Recognize the clinical presentation of Hallucinogen Persisting Perception Disorder.
Consider the proposed pathophysiology of Hallucinogen Persisting Perception Disorder.
Understand management strategies for patients with co-occurring Hallucinogen Persisting Perception Disorder and substance use disorders.

Presenting Author(s)

Julie Christensen, MD
– Psychiatry Resident, Mayo Clinic, Rochester, MN, United States
Co-Author(s)

David Fipps, DO
– Consultation Liaison Psychiatrist, Mayo Clinic, Rochester, MN, United States

J Michael Bostwick, MD, FACLP
– Professor of Psychiatry, Mayo Clinic College of Medicine, J. Michael Bostwick, Mayo Clinic, Rochester, MN, Rochester, MN, United States