Hallucinogen persisting perception disorder in adolescence: a complex case of lysergic acid diethylamide-induced visual disturbances with trauma-associated exacerbation

Hallucinogen Persisting Perception Disorder (HPPD) affects 1-5% of psychedelic users, with higher rates among recurrent LSD consumers and synthetic cannabinoid users. The disorder involves persistent visual disturbances such as palinopsia and visual snow, linked to 5-HT2A receptor dysfunction and visual cortex hyperactivation. About 20% of cases become chronic, often tied to early onset and polysubstance use. A 16-year-old developed HPPD after a second LSD use, with visual snow, micropsia, and altered object outlines that were episodic and triggered by trauma-related situations, causing significant distress and suicidal ideation. Levetiracetam initially helped but symptoms worsened after cannabis relapse; restarting Levetiracetam with abstinence led to good functional recovery, though visual snow persisted mildly.

Study at a glance

Abstract

Hallucinogen Persisting Perception Disorder (HPPD) is a condition affecting 1-5% of psychedelic users, with higher prevalence observed among recurrentLSD consumers and synthetic cannabinoid users [1]. The disorder is characterised by persistent visual disturbances including palinopsia and visual snow, along with dissociative symptoms, which have been neurobiologically linked to 5-HT2A receptor dysfunction and visual cortex hyperactivation [2];[3]. Approximately 20% of cases progress to chronic forms, often associated with early onset and polysubstance use history, necessitating comprehensive therapeutic approaches [1]. We present the case of a 16 year-old with an acute presentation compatible with HPPD after recreational use of lysergic acid diethylamide (LSD). All identifiable data has been removed. A is a 16 year-old young person who presented to an outpatient mental health service with perceptual abnormalities after using LSD for the second time. A’s symptoms had been present for 3 months prior to the assessment, and consisted of visual snow, micropsia and changes in the image definition of objects, with the outlines of objects abruptly becoming much neater. A reported that the symptoms were episodic and sudden.Since the beginning of the symptoms, A had unfortunately been through an extremely traumatic event, the nature of which will not be disclosed in order to protect A’s privacy. A found that situations linked to the trauma trigger episodes of HPPD symptoms and this caused significant distress, including significant suicidal ideation due to how overwhelming these symptoms were. A did not present with flashbacks of the traumatic event. A's functionality had been significantly impaired, with A spending most of the time at home, not going out due to fear of these symptoms reappearing. A did not present with other perceptual abnormalities, delusional beliefs or first-rank symptoms pointing towards a diagnosis of psychosis. A’s mood was low as are result of these symptoms, but denied presenting with depressive symptoms or other mood symptoms prior to the onset of HPPD. A was initially prescribed Levetiracetam up to 750mg twice a day, with initial good response and functional recovery. However, after a few weeks A’s symptoms worsened again, which led to a switch to Lamotrigine up to 50mg with no response. A eventually acknowledged believing that the symptom worsening after initial stability was due to a relapse in substance misuse (cannabis use), and requested to try Levetiracetam again with the intention to avoid drugs this time. Lamotrigine was discontinued and Levetiracetam was introduced gradually up to a dose of 750mg twice a day, with good response. A’s symptoms improved to the point where A could go back to his usual academic and social activities without being impaired by them. Although the visual snow persisted in an attenuated manner, A did not want to increase the dose of Levetiracetam or change to a different medication, and was happy with the prescription. A went on to his previous routine and also engaged in ongoing psychological support for the presenting symptoms.