The Permanent Trip:

A case of "post-hallucinogen perception disorder"

by Paul Genova, M.D.

(Adapted from author, The Thaw: 24 Essays in Psychotherapy; Pittsburgh:

Dorrance Publishing Co., 2000, pp. 17-19.)

[introductory note] Here is a situation where an experiential risk paid

off. I have never seen the visual world in quite the same way since. One

could say that the intervention here was primarily cognitive -- and I'm no

snob about that -- but I would argue that it was equally important that I

joined the patient in his isolated perceptual world as a companion.

"Trip" first came out in the Winter 1995 issue of Voices; it was

reprinted, with a commentary by the biological psychiatrist Ronald Pies, in

April 1998's Psychiatric Times, subtitled with the new nomenclature for the

problem: "Hallucinogen Persisting Perception Disorder." Pies' scientific

observations were greatly appreciated, but seemed too specialized to include

in this version.

Dan, 21, was home from college in the middle of the winter, having

dropped out after a miserable year and a half. His problems had begun about

three years before, shortly after period of drug experimentation which had

included three LSD trips. A few weeks after his final trip, newly abroad as

an exchange student, he began experiencing spontaneous visual hallucinations

including moving "dots" in the visual field, afterimages or "blurs" of moving

objects, a sense of being able to "see the air," and other phenomena

described by Abraham in 1983 (see also DSM-IV, pp.233-4) as

"post-hallucinogen perception disorder." Neither his hosts nor the European

physicians he eventually saw had any clue about what was wrong, and Dan

sensed that they were beginning to think he was a hypochondriac, so he

stopped complaining and endured this problem on his own for a year, fearing

for his sanity. Not until he started college back in the U.S. did he find

his way to a neurologist and eventually to Abraham himself, who made the

definitive diagnosis and found "persistent activation of the right posterior

temporal area" after visual evoked response testing. [The electrical activity

in the brain's visual cortex, generated in response to a test stimulus, did

not die away within the expected amount of time, but kept on going for much

longer.]

The symptoms were managed with clonazepam [trade name Klonopin, a potent

relative of the familiar Valium] on the theory that their neurologic basis

might resemble siezure activity. Dan seemed to require high and

ever-increasing dosages, and became withdrawn and depressed. He stopped

functioning in school and socially, drank alcohol more heavily, and, when he

realized what was happening to him, finally decided to come home.

My suspicion, when I began working with Dan, was that the clonazepam was

a major contributor to his depression. But my initial efforts to taper the

dose, while working in conventional psychotherapy on developmental issues

behind his sense of being punished by his perceptual affliction, met with

resistance and a florid worsening of the visual symptoms. Then, four months

into the work, came the session when I spontaneously sat next to him on the

couch, looking out the office window at a clear blue sky, and asked him to

describe what he saw. As he began I tried to "suspend" my habitual state of

consciousness and see whether any of his "hallucinations" were visible to me.

To my surprise, I was immediately able to see irregular linear shapes

floating slowly across the visual field. When I blinked, they would change

shape or position. I began describing this to Dan in great detail so that he

would have no doubt that I was not simply repeating his descriptions, but

actually having my own similar experiences. Clearly, these "shooters" seemed

to be generated by something on the surface of the eye to which we don't

normally attend. I invite the reader to try this for him- or herself.

In this and a few succeeding sessions I was able to experience with Dan

most of the phenomena of his illness, including visual "trails" of moving

objects, various line-shape illusions such as level bookshelves slanting,

"aeropsia" (a sense of bright whiteness in the air between us and observed

objects), and "dancing bright spots" originating between the letters and

words on a printed page. With minimal information from him, I could describe

these convincingly, at times even completing his sentences. We both found

this a strangely exhilarating activity. It was clear to me, however, that I

did not experience these visual phenomena as intensely and persistently as

did he, and that I could ignore them at will.

Whatever the physiological mechanism of this disorder may be, it is

obvious that functionally a failure of a normal pre-conscious "editing"

process was occurring, whereby additional irrelevant aspects of raw

perceptual experience were reaching consciousness.

Dan reported a great sense of relief and "normalization" as a result of

these few sessions. Tapering of his clonazepam was now accomplished with

relative ease down to a very minimal dosage. Predictably, the major

depressive symptoms resolved. There was much else to talk about in a year of

therapy, but we both agreed, and still agree several years later, that our

perceptual experiment was the turning point.

Before our mutual experiences, the symptoms "meant" that Dan was crazy,

different from other people, alone forever in a distorted visual universe.

This triggered a vicious cycle, or "positive feedback loop," in which Dan's

anxiety about this situation served to amplify the symptoms in his conscious

awareness and continually re-focus his attention upon them. Thus the ordinary

distractions of everyday experience were unable to perform their potentially

useful role, powerless to divert him from an "illness" which became the

center of his life and, expectably, a crystal nidus for fantasies of

punishment which sprang from their usual developmental lairs. He was quite

capable of understanding the sources of this hitherto-latent shame, but this

did not impact his perceptual distortions one whit.

After the "normalization," though, Dan had only the symptoms themselves

with which to contend, and not the snowballing anxiety and sense of

retribution. He became more distractible in the healthy sense, his conscious

attention freer to roam, or focus elsewhere (studies, relationships). And

through the experience (and perhaps, I'll allow, as a result of our

developmental work as well-- sudden "miracles" usually have some amount of

groundwork preceding them) he had found his way to a more thoroughgoing

self-acceptance.

Dan returned to a different college, did very well, and got his degree.

He now works in the mental health field. For the past seven years the same

low dose of clonazepam has been necessary, but with it, except in times of

extreme stress or physical fatigue, he is rarely bothered by visual symptoms.