# Hallucinogen Persisting Perception Disorder aka HPPD



## David Kozin

The following is some information on a disorder called Hallucinogen Persisting Perception Disorder. Although the DSM diagnosis strictly limits the disorder to the visual perceptual component of this drug-induced disorder, it is often accompanied by Depersonalization and derealization. Although these are considered seperate diagnostic entities (technically derealization is not even considered a specific diagnosis -- perhaps at best recognized as a clinicially vague term for a specific "feeling" individuals have. ) I hope that this site continues to grow, and information can be used to help define the complex symptomology of permanent drug-induced disorders.

Lysergic acid diethylamide (LSD) was once considered a unique substance because a percentage of users would experience manifestations of the hallucinogenic experience even while not actively under the influence of a hallucinogen. However, with the recent emergence of newer hallucinogens, it appears that many other hallucinogens may cause HPPD. These substances may include many of the tryptamine class of hallucinogens and also potentially some of the phenethylamines, notably Ecstasy and Mescaline. We do know that the cause of these recurrent episodes is not the long-term presence of the hallucinogenic molecule still in the body, we do not know exactly why these episodes occur or why only a certain population of people will experience HPPD despite the widespread use of this class of drugs.

HPPD comes in two different forms. One hallucinogen user, while not currently intoxicated, may occasionally notice a spontaneous LSD-like flashback, which will go away after a short time. On the other hand, another user may experience constant, irreversible, LSD-like perceptual disturbances that persist 24 hours a day; they can continue for the rest of their life. These different "flashback" experiences lead to what I believe form two subtypes of the disorder officially called Hallucinogen Persisting Perception Disorder (HPPD). The first type that I have described is the "flashback" type. These are brief, recurrent, and reversible occurrences in which the past hallucinogen user experiences an aspect of the psychedelic trip. These occurrences are often viewed by the person as a benign experience; sometimes they are even considered a "free trip". However, these flashbacks can be accompanied by panic, severe anxiety, and fear. This can lead to feelings of depression and guilt; the user may blame themselves for having "brought this experience on themselves". Flashbacks of this sort have been compared to Post-Traumatic Stress Disorder and in some cases are treated this way.

The second type is more accurately referred to as Hallucinogen Persisting Perception Disorder. This disorder is the long-term, intermittent or continuous, slowly reversible or irreversible, experience of one or more of the LSD-like visual perceptual disturbances which causes distress or impairment in social, occupational or other important areas of functioning (DSM-IV, 1994). People with HPPD are acutely aware of these perceptual disturbances and often seek psychiatric help. The symptoms can range from merely seeing afterimages of objects in their vision (often producing a strobe-like effect at night with moving lights) to having an entire group of perceptual disturbances. These disturbances may include stationary objects sliding back and forth, static imposed over their vision, trails of moving images, positive and negative afterimages, geometric patterns imposed on objects, et cetera. For a more comprehensive list of symptoms, click on the symptoms link on the blue side bar. This disorder may slowly fade away, but often lasts longer than 5 years and could potentially affect the person for the rest of their lives. Although this disorder can be extremely debilitating, many HPPDers learn to accept their condition and become accustomed to the unusual visual distortions. Unlike the hallucinations of LSD-induced psychosis or general psychosis, a person with HPPD realizes that these perceptions are not real. Additionally, this condition mostly impairs the person's visual system and leaves their auditory system within normal ranges. The mechanisms underlying HPPD are not known at this time. It is difficult to have accurate information based on the past use of drug users that develop HPPD. A person can become impaired by HPPD after only a single experience with LSD.

There is no magic bullet cure for HPPD. However, clinicians, researchers, and patients have reported cases where HPPD symptoms were significantly reduced with medications. HPPD is a rare disorder and it is not uncommon for clinicians to be unaware of the disorder. However, Hallucinogen Persisting Perception Disorder was created as an official diagnosis entity in the DSM-IV (Diagnostic and Statistical Manual for Mental Disorders version IV) in 1994 by the Substance-Related Disorders Work Group.

The symptoms of HPPD are difficult to describe. If the reader has injested a hallucinogen in the past, HPPD can roughly be described as "being on a small dose of LSD without tripping." It is particularly difficult when attempting to describe the complex visual phenomena, which is experienced by HPPDers, to a person who has no experience with hallucinogenic drugs. In addition, the DSM-IV diagnosis criteria do not clearly and specifically describe the particular visual symptoms that must exist in order to diagnose HPPD.

A clinical attempt at listing the symptoms:
In 1983, Dr. Henry Abraham examined 16 different visual symptoms in an HPPD characterization study and this list of symptoms is still the most comprehensive in print. The following descriptions are based partly on Dr. Abraham's descriptions, and also on the personal experience of patients with HPPD. People with HPPD can have any combination of these symptoms. The severity of symptoms is also very diverse. To be considered as a possible "candidate" for HPPD you must have a history of at least one exposure to a hallucinogen. Note that other disorders may have similar symptomology and that having some of these symptoms may indicate other conditions (e.g., anatomical lesions and infections of the brain, visual epilepsies) or another mental disorder (e.g., delirium, dementia, Schizophrenia) or hypnopompic hallucinations. It is also important to note that HPPD is a visual disorder. HPPD does not include symptoms of depression, *depesonalization*, or panic attacks. These are seperate disorders as far as the diagnositc criteria is concerned. However, these comorbid symptoms often occur with HPPD and their relationships are unknown.

Symptom Descriptions
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Acquired Color Confusion: Sometimes it is difficult for a person with HPPD to tell the difference between two colors and they may actually confuse one color with another. An HPPDer may look at a black sweater and experience the sweater turning a deep purple. It may be difficult to tell the difference between a navy blue sock and a dark brown sock. Although people with normal perception may have similar difficulty, the person with HPPD can actually watch a color change before their eyes. The author of this site has seen black print in a book turn bright green as though the book were printed in neon green print.

Difficulty Reading: People with HPPD may find it difficult to read for multiple reasons. Some complain of a loss of concentration. Others describe the text swaying back and forth and positive and negative afterimages (see the descriptions below) of the text set onto the background of the page. "Several complained that this last phenomenon would create a bichromatic alphabet soup of images that made study difficult." (Abraham 1993)

Flashes of Color: Suddenly, without any apparent reason, a person can see a flash of bright light. This flash can occur as a metallic "star" that flashes in one's vision or may occur as sheets of light that appear then quickly disappear.

Geometric Pseudohallucinations: HPPDers may see geometric figures appear in their vision when the eye is either open or closed. A person with HPPD realizes this is not a real figure, for this reason the hallucination is more accurately described as a pseudohallucination. Some people describe sparkles, visual fireworks, colored or transparent doughnut shaped images, blobs of jelly like transparent balls, or complex shapes and figures.

Halos Around Objects: Some people with HPPD experience a halo that would surround objects and people. This halo can extend for a few inches from the object.

Illusions of Movement: Some people with HPPD report that stable objects would appear to move side to side or wave up and down. Some will see objects that appear to slide across the floor or they would feel that the floor is floating downwards. Some may experience the walls waving or feeling that their keys on their computer keyboard sway back and forth. This symptom was noted by Dr. Abraham as being quite common and reports that these symptoms came to be known as PIPs, an acronym for "perceptions in the periphery." (Abraham 1983)

Imagistic Phosphenes: "These are phosphenes of unbidden, formed images (not geometric patterns) generated on closing an eye [and of pressing on it] with a finger. Two subjects within their first week of an LSD exposure were able to see images when the researcher exerted gentle digital pressure on the eyes. One saw the face of God, and the second a Mickey Mouse cartoon." (Abraham 1983)

Intensified Colors: HPPDers report that looking at a colored object can make the object suddenly change in brightness. This brightness could also go away as quickly as it came about.

Macropsia: This describes the condition when an object is perceived as being abnormally large. Objects will appear huge for a few moments and then suddenly appear at their normal size.

Micropsia: The opposite of macropsia. This is the perception of objects smaller than they really are. Someone may look at their arm and think that it is really small and note that it seems to be distant.

Negative Afterimages: Some people with HPPD will look at an object and when they look away from the object they will see a complementary "shadow" of that object. An HPPDer may be looking at a green garden hose and then look away to notice an afterimage of that hose in red in their vision. People without HPPD may also see these images if they stare at an object for awhile. You may have tried this activity while reading through a book of illusions and possibly stared at a the flag of the United States in which the colors were presented as green and yellow and when you looked away after staring at that image you saw an afterimage of it in their correct blue and red colors. For an HPPDer, looking at an object for a brief moment can produce a powerful and long lasting afterimage.

Positive Afterimages: A person with HPPD may look at a blue object and then upon looking away from that object, see a blue shadow. An imprint of the object has been placed on their vision. Staring at text in a book and then looking up at the wall to notice blurry lines of that text placed on the wall is another common example.

Pareidolias: This is when an HPPDer sees an image within an image. It is similar to when you stare up at the clouds to see faces or objects in the cloud. An HPPDer however, might be walking on a wood floor and see dozens of faces in the swirls of the wood grain. These images are quite concrete to the HPPDer. The person with HPPD does realize these images are false.

Static Vision: Some people with HPPD experience what appears like static all over their vision. This symptom is really noticeable at night when an HPPDer looks around and it may actually appear as if there were a television in the room projecting static all over the room.

Floaters: Some people with HPPD become acutely aware of the material that floats on the surface of the eye. These floaters may look like bacteria and appear to be jelly-like in form. They are often seen when looking up at a blue sky.

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Often, individuals that seek help for HPPD have Depersonalization -- and often the DP symptoms are the most disturbing of an individual's "symptom complex" of their drug-induced disorder.

If you are interested in hearing more about HPPD, you can Private Message me and I will be happy to discuss that subject.

Best wishes, this is great board.

David


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## Benjavaz

I believe that HPPD is a form of drug-induced depersonalization/derealization. A lot of people with DPDR who have never touched hallucinogens report visual snow, perceived motion of stationary objects, an acute awareness of floaters, afterimages, and a lot more. I think that hallucinogens just increase your awareness and the severity of these distortions a lot.


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## curiousmind

Benjavaz said:


> I believe that HPPD is a form of drug-induced depersonalization/derealization.


False and uninformed belief.

HPPD is a distinct disorder from depersonalization-derealization disorder according to the DSM, and in the case of the latter disorder there is no clinical variance between the drug-induced and non-drug-induced "versions" [link].


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