HPPD

Generell information

HPPD är förkortningen för "Hallucinogen Persisting Perception Disorder" vilket kan översättas till Posthallucinatorisk perceptionsstörning. Det är en störning av synintrycken som orsakats av hallucinogener och är såpass plågsam att man upplever ett handikapp i sitt dagliga leverne eller försämrad livskvalitet. HPPD skulle kunna liknas med en synlig form av tinnitus, men istället för hörbara pip eller brus så upplever den som drabbas av HPPD visuella störningar. De klassiska visuella effekterna av drogen går inte över.

Symptomen kan men måste inte vara något av följande:

• Saker rör sig, zoomas in eller ut i direktseendet eller periferin av synfältet.
• Färghallucinationer/flimmer eller brus när man tittar och/eller när man blundar.
• Väggar och platta ytor tycks vibrera eller pulsera eller får mönster.
• Föremål ändrar färg eller form, eller ser större eller mindre ut än de verkligen är (Macropsia/Micropsia), alternativt närmare/längre bort (Pelopsia/Teleopsia).
• Föremål har halos (ljus/gloria runt sig)
• Föremål lämnar "efterbilder" när man inte längre tittar på dessa längre eller stänger ögonen (Palinopsia).

Kraven på diagnosen som måste uppfyllas är att synintrycken påverkas till en sådan grad att det upplevs som ett problem. Det måste även ha uppkommit omedelbart efter bruk av hallucinogener och det måste vara beständigt över tid långt efter att drogen lämnat kroppen. Läs mer om diagnoskraven längre ner.

HPPD behöver inte vara en diagnos man behöver leva med livet ut. Många blir av med sina besvär, men det har tagit månader, ibland flera år. Avhållsamhet från hallucinogena droger är ett måste, men i vissa fall även cannabis och alkohol. Ibland kan antiepileptiska läkemedel och benzodiazepiner lindra symptomen. Antiepileptikan lamotrigin och antidepressanten reboxetin nämns även som möjliga läkemedel.

Halpern et al. skriver i sin metastudie från 2016 att HPPD-diagnoserna tenderat att inkludera fenomen som i den klassiska litteraturen kallats flashbacks samt visuella störningar. Författarna delar därför upp HPPD i två klasser. Klass 1 som är flashback-liknande och Klass 2. När det gäller klass två så anges följande om läkemedel för behandling:

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For those claiming Type 2 HPPD, improvements have been reported with sunglasses (Abraham 1983) and psychotherapy (Abraham et al.1996). With Type 2 HPPD, antipsychotic drugs worsened some symptoms (Abraham and Mamen 1996; Morehead 1997, Lerner et al. 2002; Goldman et al. 2007). SSRIs worsened 4 cases documented by Markel et al. (1994), but other clinicians report improvements (Young 1997; Aldurra and Crayton 2001). Anti-seizure drugs and clonidine were also used with some success (Alarcon et al. 1982; Lerner et al. 2000). It is not easy to determine how best to treat HPPD given this literature. The widely variable, partially contradictory findings may require us to speculate on placebo effects, idiosyncratic neurochemistry, and spontaneous recovery, or perhaps more simply, an inadequately defined HPPD. — Halpern et al. (2016)

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Prevalens

HPPD kan uppkomma efter att ha brukat hallucinogener så lite som en enda gång. Troligtvis är vissa individer känsligare än andra. Men det är vanligare bland personer som använt stora doser med hög frekvens. En del upplever att små begynnande tecken på visuella synstörningar blivit bestående efter ytterligare trippar. Kombinationer med alkohol och stimulanter har också visat sig förvärra symptomen.

Mycket information om prevalensen av HPPD saknas, främst för att skadan är sällsynt förekommande.

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The incidence of HPPD is unknown, although it is thought to be very uncommon given the relatively few cases reported out of the millions of hallucinogen doses consumed since the 1960s (Halpern and Pope, 2003) Although the term ‘flashback’ is sometimes used interchangeably with HPPD, the former term is often used to describe any brief perceptual effects reminiscent of acute hallucinogen effects but occurring beyond acute hallucinogen use, usually in the absence of clinical distress or impairment (Lerner et al., 2002). Indeed, many illicit hallucinogen users report some brief visual abnormalities occurring after acute hallucinogen effects, but only for a small minority of users are these effects troubling or impairing enough to be considered clinically significant or warrant the diagnosis of HPPD (Lerner et al., 2002; Baggott, et al., 2006). Many illicit users regard such sub-clinical effects as benign and pleasurable (Strassman 1984; Lerner,et al., 2002; Frecska and Luna, 2006). Importantly, the incidence of HPPD or other perceptual abnormalities appears to be much lower in therapeutic or research contexts with careful screening and preparation than in the context of illicit recreational use, which may include the confounds of polydrug use and unscreened psychiatric disorders (Cohen, 1960; McGlothlin and Arnold, 1971; Strassman 1984; Halpern and Pope, 2003). — Johnson et al. (2008)

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Interestingly, Type 2 HPPD was never clearly reported during the 1960s when millions of Americans took LSD on a regular basis with less knowledge about hallucinogens and more resultant complications. HPPD was not described in the comprehensive retrospective surveys of LSD use in psychotherapy in approximately 10,000 patients during the 1950–1960s (Cohen 1960; Malleson 1971; Passie 1997). — Halpern et al. (2016)

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En studie från 2010 visade att runt 4% av LSD-brukarna som svarade på ett webbformulär upplevde effekter som skulle kunna klassas som HPPD:

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We used an online questionnaire to document the symptoms and relationship to drug use of unusual visual phenomena in hallucinogen users. 16,192 individuals viewed the information sheet and 2679 were included in the study. Of these, 224 reported having unrelated diagnoses associated with unusual visual experiences and were excluded from main analyses. Most (60.6%) of the remaining 2455 participants reported having experienced drug-free visual experiences that resembled hallucinogen effects. Probability of experiencing constant or near-constant symptoms was predicted by greater past exposure to specific hallucinogens, including lysergic acid diethylamide (LSD). Although symptoms were common, few (104, or 4.2% of the sample) found them distressing or impairing enough to consider seeking treatment. — Bagott et al. (2010)

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Även andra formulär, litteraturgenomgångar och fallbeskrivningar i övrigt indikerar att problemet verkar vara mer associerat med LSD än andra psykedeliska droger där fenomenet kan anses vara sällsynt. Man kan notera att flera av de studier som hänvisas till angående visuella störningar (HPPD och flashbacks) är mycket gamla (publicerades före 1980) och kan ha vetenskapliga brister.

En nyare studie som har avgränsat sig till resultat från modern tid gör följande konstaterande:

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According to the literature, we found that the majority of HPPD cases have been induced by LSD or phencyclidine (PCP) (14 studies, 294 patients). The use of cannabis has been associated with the development of perceptual distortions in seven patients. In one case, it was associated with 3,4-Methylenedioxymethamphetamine (MDMA) and in another case with PCP. In two patients, visual distortion followed the consumption of synthetic cannabinoids. Lauterbach et al. reported the unique case of HPPD induced by the atypical antipsychotic Risperidone. — Martinotti (2018)

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MDMA också lyftas fram som en drog som möjligen också har högre riskfaktor:

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Moreover, we present 31 new HPPD cases that link HPPD to the use of ecstasy (MDMA), which is known to reverse serotonin reuptake and acts as agonist on 5-HT2A receptors. The available evidence suggests that HPPD symptoms may be a result from a misbalance of inhibitory-excitatory activity in low-level visual processing and GABA-releasing inhibitory interneurons may be involved. However, high co-morbidities with anxiety, attention problems and derealization symptoms add complexity to the etiology of HPPD. Also, other perceptual disorders that show similarity to HPPD cannot be ruled out in presentations to clinical treatment. Taken together, evidence is still sparse, though low-level visual processing may play an important role. A novel finding of this review study, evidenced by our new cases, is that ecstasy (MDMA) use may also induce symptoms of HPPD. — Litjens (2014)

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Diagnos

Följande kriterier måste uppfyllas för att diagnosen HPPD skall kunna fastställas enligt DSM-IV:

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The essential feature of Hallucinogen Persisting Perception Disorder (Flashbacks) is the transient recurrence of disturbances in perception that are reminiscent of those experienced during one or more earlier Hallucinogen Intoxications. The person must have had no recent Hallucinogen Intoxication and must show no current drug toxicity (Criterion A). This reexperiencing of perceptual symptoms causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion B). The symptoms are not due to a general medical condition (e.g., anatomical lesions and infections of the brain or visual epilepsies) and are not better accounted for by another mental disorder (e.g., delirium, dementia, or Schizo- phrenia) or by hypnopompic hallucinations (Criterion C). The perceptual disturbances may include geometric forms, peripheral-field images' flashes of color, intensified colors, trailing images (images left suspended in the path of a moving object as seen in stroboscopic photography), perceptions of entire objects, afterimages (a same-colored or complementary-colored shadow of an object remaining after removal of the object), halos around objects, macropsia, and micropsia. The abnormal perceptions that are associated with Hallucinogen Persisting Perception Disorder occur episodically and may be self-induced (e.g., by thinking about them) or triggered by entry into a dark environment, various drugs, anxiety or fatigue, or other stressors. The episodes usually abate after several months but can last longer. Reality testing remains intact (i.e., the person recognizes that the perception is a drug effect and does not represent external reality). In contrast, if the person has a delusional interpretation concerning the etiology of the perceptual disturbance, the appropriate diagnosis would be Psychotic Disorder Not Otherwise Specified. Diagnostic Critera: A. The reexperiencing, following cessation of use of a hallucinogen, of one or more of the perceptual symptoms that were experienced while intoxicated with the hallucinogen (e.g.. geometric hallucinations, false perceptions of movement in the peripheral visual fields, flashes of color, intensified colors, trails of images of moving objects, positive afterimages, halos around objects, macropsia, and micropsia). B. The symptoms in Criterion A cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The symptoms are not due to a general medical condition (e.g., anatomical lesions and infections of the brain. visual epilepsies) and are not better accounted for by an- other mental disorder (e.g., delirium, dementia, schizophrenia) or hypnopompic hallucinations. — American Psychiatric Association

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To strictly meet these criteria, an individual must display several attributes. First, hallucinogen use must precede the syndrome; if an individual has pre-existing perceptual symptoms that persist and/or evolve after hallucinogen intoxication, a diagnosis of HPPD is not justified. Moreover, DSM-IV suggests in its text that HPPD persists ‘‘long after the use of hallucinogens has stopped’’ (p. 313). Thus, symptoms lasting only days after hallucinogen ingestion are presumably insufficient to represent HPPD. Second, the word ‘reexperiencing’ in criterion A, together with the requirement for ‘distress or impairment’ in criterion B, suggests that perceptual phenomena should be sufficiently striking to be outside the range of normal experience. Simply seeing bright spots in front of one’s eyes upon entering a dark room, for example, probably should not qualify for the diagnosis of HPPD. Third, as indicated in criterion C, alternative etiologies for unusual perceptual experiences must be on-sidered before diagnosing HPPD. DSM-IV cites visual epilepsies, migraine, delirium, dementia, schizophrenia, and hypnopompic hallucinations as specific disorders to rule out. Less clear in DSM-IV is whether to exclude acute intoxication with other drugs that might cause visual disturbances. On the one hand, DSM-IV specifies that ‘‘the person must. . . show no current drug toxi-city. . .’’ (p. 233), but the same text specifies that the abnormal perceptions may be ‘‘triggered’’ by ‘‘various drugs’’ (p. 233). Despite these somewhat contradictory statements, prudence dictates withholding the diagnosis of HPPD in cases where current or prior use of a drug may be causing or contributing to aberrant perceptual experiences. Other conditions to be ruled out before diagnosing HPPD should be posttraumatic stress dis-order (PTSD) and depersonalization and derealization associated with severe anxiety and depression. Finally, one must exclude other hallucinogen-induced disorders recognized by DSM-IV, such as hallucinogen-induced psychotic, mood, or anxiety disorders — Halpern, 2003

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I DSM-V som är den senaste revisionen så är diagnoskraven för "Hallucinogen Persisting Perception Disorder DSM-5 292.89 (F16.983)" desamma som DSM-IV

Kan HPPD ha en psykologisk förklaring?

Halpern noterar att det finns stora problem att vetenskapligt härleda HPPD till en fysisk förklaring, att vissa receptorer skadas etc. Därtill finns det en mängd fakta som pekar i olika eller motsatta riktningar. Exempelvis finns det droger som inte är hallucinogener som ger samma fenomen. När man studerar personer med HPPD finner man också en rad märkliga saker, allt från att personernas psykiska hälsa kan vara en riskindikator tillsammans med tinnitus och dålig koncentrationsförmåga. Därtill har många har därtill upplevt visuella effekter redan innan trippen. Det finns dessutom många som upplever att effekterna inte uppstod omedelbart efter den hallucinogena drogen togs, det kunde dröja dygn eller veckor. Därtill finns hög prevalens av depersonalisering och derealisation bland personer med HPPD. Halpern förestår en förklaring där HPPD möjligen orsakas av ångest och kan ses som besläktat med PTSD eller andra psykiska stressreaktioner.

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The DSM-V states that HPPD requires that the disturbances subsequent to hallucinogen use should be reminiscent of what was experienced during intoxication. Although all subjects reported primarily visual symptoms, by far not every disorder of vision detailed was also reminiscent of the triggering intoxication. One possibility is that hallucinogen use triggered subsequent disordered processing of vision beyond the alterations originally encountered. Another possibility is that those with Type 2 HPPD have a pre-existing set of subclinical symptoms that can be aggravated by various experiences, particularly by hallucinogens. Acute intoxication and later awareness of abnormal, “overactive” vision may alarm those with a pre-existing propensity for anxiety and may trigger states of more or less depersonalization in individuals with an appropriate predisposition. If Type 2 “HPPD” symptoms are not only repetitions of a drug experience and/or existed prior to drug intoxication in milder intensity, this suggests that HPPD goes beyond hallucinogen use. The DSM-V criterion of re-experiencing focuses on drug exposure, but the constellation of symptoms is apparently more complex. ... Even with a limited number of subjects, our data provide some tentative insight into whomight be at risk for Type 2 HPPD. Those with individual or family histories of anxiety, who have pre-drug use complaints of tinnitus, visualfloaters, and concentration problems, may be most susceptible for later development of persisting perception disorder (of Type 2 HPPD), particularly after LSD and or psilocybin. Our data also indicate that non-hallucinogenic substances can trigger HPPD symptoms. Prominent anxiety during the drug intoxication, benzodiazepine anxiolysis appearing most helpful in reducing HPPD symptoms, and Dissociative Experiences Scale results (30 % reporting clinically significant pathology) together suggest that HPPD may be an anxiety disorder not unlike PTSD, where the triggering drug experience is the traumatic event. — Halpern et al. (2016)

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Externa länkar:

HPPD Online

Erowid HPPD Information

HPPD Forskning och medicinering

Wikipedia: Hallucinogen persisting perception disorder