Introduction
Substance related disorders are composed of two groups: the substance - use disorders (dependence and abuse) and the substance induced disorders (intoxication, withdrawal, delirium, dementia, amnesia, psychosis, mood disorder, sexual dysfunction and sleep disorders.). A wide variety of substances are produced for medicinal purposes. These include central nervous system stimulants, CNS depressants and other over the counter preparations designed to relieve nearly every kind of human ailment, real or imagined. Some illegal substances have achieved a degree of social acceptance by various sub cultural groups within our society. These illegal substances include hallucinogens and inhalants too.
HALLUCINOGENS RELATED DISORDERS
Introduction
The term hallucinogens refers to a classification of drugs that produces euphoria or dysphoria, altered body image, distorted or sharpened visual and auditory perception, confusion, in co-ordination and impaired judgement and memory. Hallucinogens are natural and synthetic substances that are variously called psychedelics or psychotomimetics because, besides inducing hallucinations, they produce a loss of contact with reality and an experience of expanded and heightened consciousness.
A profile of the substance:
- Hallucinogenic substances are capable of distorting an individual's perception of reality. They have the ability to alter the sensory perception and induce hallucinations. For this reason they have been referred to as mind expanding. Some of the manifestations have been likened to a psychotic break.
- Substance induced hallucinations are visual most often, perceptual distortions have been reported by some users as spiritual, as giving a sense of depersonalization, or as being at peace with self and the universe.
- Others, who describe their experiences as "bad trips", report feelings of panic and a fear of dying or going insane.
- A common danger reported with hallucinogenic drugs is that of" flashbacks, or a spontaneous recurrence of the hallucinogenic state without ingestion of the drug.
- Recurrent use can produce tolerance, encouraging users to resort to higher and higher dosages. No evidence of physical dependence is detectable when the drug is withdrawn; however recurrent use appears to induce a psychological dependence.
Historical aspects:
- Archaeological data obtained with carbon 14 dating suggests that hallucinogens have been used as a part of religious ceremonies and at social gatherings by Native Americans for as long as 7000 years.
- 1943: LSD was first synthesized by Dr. Albert Hoffman. It was used as a clinical research tool to investigate the biochemical etiology of schizophrenia. It soon reached the illicit market, however and its use began to overshadow the research effort.
- Late 1960s: the abuse of hallucinogens reached its peak
- 1970s: warned the use of hallucinogens
- 1980s: hallucinogens returned to favour with the so called designer drugs (3, 4 methylene dioxyamphetamine and methoxy amphetamine.
- One of the most commonly abused hallucinogen today is PCP even though many of its effects are perceived as undesirable.
- Several therapeutic uses of LSD have been proposed, including the treatment of chronic alcoholism and the reduction of intractable pain such as occurs in malignant disease.
Categories:
1. Naturally occurring hallucinogens
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Generic names |
Common street names |
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Mescaline( primary active ingredient of the peyote cactus) |
Cactus, mesc, mescal, half moon, big chief, bad seed, peyote |
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Psilocybin and psilocin( active ingredients of psilocybe mushrooms) |
Magic mamushroom, god's flesh, shrooms |
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Ololiuqui( morning glory seeds) |
Heavenly blue, pearly gates, flying saucers |
2. Synthetic compounds
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Generic name |
Common street names |
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Lysergic acid diethylamide (LSD) synthetically produced from a fungal substance found on rye or a chemical substance found in morning glory seeds. |
Acid, cube, big D, California sunshine, blue dots, sugar, peace tablets, cupcakes |
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Dimethyltryptamine(DMT) and Diethyl trypatmine (DET) |
businessman's trip |
Pattern of use/abuse:
Use of hallucinogens is usually episodic. Because cognitive and perceptual abilities are so markedly affected by these substances, the user must set aside time from normal daily activities for indulging in the consequences. The use of LSD does not lead to physical dependence or withdrawal symptoms.
However tolerance does develop quickly and to a high degree. In fact, an individual who uses LSD repeatedly for a period of 3 to 4 days may develop complete tolerance to the drug. Recovery from the tolerance also occurs very rapidly so that the individual is able to achieve the desired effect from the drug repeatedly and often.
PCP is usually taken episodically, in binges that can last for several days. Some chronic users take the substances daily, however. Physical dependence does not occur with PCP; however, psychological dependence characterized by craving for the drug has been reported in chronic users, as has the drug has been reported in chronic users, as has the development of tolerance.
Psilocybin in an ingredient of the Psilocybin mushroom indigenous to the United States and Mexico. Ingestion of these mushrooms produces an effect similar to that of LSD but of shorter duration. This hallucinogenic chemical can now be produced synthetically.
Mescaline is the only hallucinogenic compound used legally for religious purposes today by members of the Native American church of the United States.
CLASSIFICATION
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DSM IV |
ICD 10 |
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Hallucinogen use disorders
Hallucinogen induced disorders
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F10-19: Mental and behavioural disorders due to substance use. F16: mental and behavioural disorders due to use of hallucinogens. Acute intoxication due to Hallucinogen Harmful use Hallucinogen Hallucinogen dependence syndrome Hallucinogen withdrawal state Hallucinogen withdrawal state with delirium Hallucinogen induced psychotic disorder Hallucinogen induced amnestic syndrome Hallucinogen induced residual and late onset psychotic disorder |
Hallucinogen dependence and hallucinogen abuse: Long term hallucinogen use is not common. No physical addiction occurs although psychological dependence occurs.
Hallucinogen intoxication: Intoxication with hallucinogens is defined in DSM IV -TR as characterized by maladaptive behavioural and perceptual changes and by certain physiological signs. The differential diagnosis for hallucinogen intoxication includes anticholinergic and amphetamine intoxication and alcohol withdrawal.
DSM IV -TR diagnostic criteria for hallucinogen intoxication:
a. Recent use of a hallucinogen
b. Clinically significant maladaptive behavioural or psychological changes.( marked anxiety, or depression, ideas of reference, fear of losing one's mind , paranoid ideation, impaired judgement, or impaired social or occupational functioning) that developed during, or shortly after hallucinogen use
c. Two or more of the following signs, developing during, or shortly after, hallucinogen use:
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- Papillary dilation
- Tachycardia
- Sweating
- Palpitation
- Blurring of vision
- Tremors
- Inco-ordination
d) The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
DSM IV -TR criteria for hallucinogen persisting perception disorder: (flashbacks)
Long after ingesting a hallucinogen, a person can experience a flashback of hallucinogenic symptoms. This syndrome is diagnosed as hallucinogen persisting perception disorder. Flashbacks are spontaneous, transitory recurrences of the substance- induced experience. Most flashbacks are episodes of visual distortion, geometric hallucinations, hallucinations of sounds or voices, false perceptions of movements of peripheral fields, flashes of colour, trails of images from moving objects, positive after images and halos, macropsia, micropsia, time expansion, physical symptoms or relieved intense emotion. The episodes usually last a few seconds to a few minutes, but sometimes lasts longer. Most often even in the presence of distinct perceptual disturbances; the person has insight into the pathological nature of disturbance. Suicidal behaviour major depressive disorder and panic disorder are potential complications.
Hallucinogen intoxication delirium: A relatively rare disorder beginning during intoxication in those who have ingested pure hallucinogens. Hallucinogens are often mixed with other substances, however, and the other components or their interactions with the hallucinogens can produce clinical delirium.
Hallucination induced psychotic disorders: If psychotic symptoms are present in the absence of retained reality testing, a diagnosis of hallucinogen- induced psychotic disorder may be warranted. The most common adverse effect of LSD and related substances is a bad trip" an experience resembling the acute panic reaction to cannabis but sometimes more severe, a bad trip can occasionally produce true psychotic symptoms. The bad trip generally ends when the immediate effects of the hallucinogen wear off, but its course is variable.
Hallucinogen induced mood disorder: Mood disorder symptoms accompanying hallucinogens abuse can vary. Abusers may experience manic- like symptom feelings and ideas or mixed symptoms. As with the hallucinogen induced psychotic disorder symptoms, the symptoms of hallucinogen induced mood disorder usually resolve once the drug has been eliminated from the person's body.
Hallucinogen induced anxiety disorder: Hallucinogen induced anxiety disorder also varies in its symptom pattern, frequently report panic disorder with agoraphobia.
Hallucinogen- related disorder not otherwise specified: When a patient with a hallucinogen related disorder does not meet the diagnostic criteria for any of the standard hallucination related disorders, the patient may be classified as having hallucinogen related disorder not otherwise specified.
Clinical features:
Lysergic acid Diethylamide (LSD):
Physiological symptoms from LSD are typically few and relatively mild. Dilated pupils, increased deep tendon reflexes and muscle tension, and mild motor in coordination and ataxia are common. Increased heart rate, respiration, and blood pressure are modest in degree and variable, as nausea, decreased appetite and salivation.
The onset of action of LSD occurs within an hour, peaks in 2 to 4 hours, and lasts 8 to 12 hours. The sympathomimetic effects of LSD include tremors, tachycardia, hypertension, or hyperthermia can occur with hallucinogenic use.
Phenethylamines:
These are compounds with simple chemical structure and structural similarity to the neuro transmitters dopamine and norepinephrine.eg: Mescaline and MDMA (member of 3,4 methylene dioxyamphetamine)
a) Mescaline:
It is usually consumed as peyote "buttons" picked from small blue- green cacti Lophophora williamsii and Lophophora diffusa. Peyote is not casually consumed usually because of its bitter taste and sometimes severe nausea and vomiting preceding the hallucinogenic effects.
b) MDMA:
It produces an altered state of consciousness with sensory changes and most important for some users, a feeling of enhanced personal interactions.
Effects of hallucinogens
Effects of hallucinogens depend on:
- how much is taken
- height and weight of the individual
- general health
- Mood
- past experience with hallucinogens
- used hallucinogens on their own or with other drugs
- Uses alone or with others, at home or at a party, etc.
The effects of hallucinogens are not easy to predict. The effects are different for different people and at different times. The main effects of hallucinogens are changes in the way you perceive things with your senses. They can include strange sensations such as floating or body becoming part of another object. Some people find such unusual sensations interesting and pleasant, while to others these same effects are unpleasant and disturbing.
Immediate effects
The effects of hallucinogens begin within half an hour of taking the drug, are strongest in three to five hours, and last for up to 12 hours.
They can include:
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Physiological effects: |
Psychological effects |
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Two types of toxic reactions are known to occur. This may include:
Bad trips
The first is the panic reaction, or 'bad trip', and it is common among first time users. Effects of a bad trip can include:
- extreme anxiety or fear
- frightening hallucinations (e.g. spiders crawling on the skin)
- panic, leading to taking risks (e.g. running across a busy street)
- feelings of 'losing control' or 'going mad'
- paranoia (feeling that other people want to harm you)
- Suicide or violence (rare).
Flashbacks:
There are few known long term effects from hallucinogens. It includes the transient, spontaneous repetition of a previous LSD induced experience that occurs in the absence of the substance, can happen days, weeks or even years after taking the drug.
Flashbacks can include visual hallucinations and other effects. They can happen without warning, last for a minute or two and can be disturbing.
Flashbacks may be triggered by using other drugs or by stress, tiredness or physical exercise. Regular users are more likely to experience flashbacks than people who only use the drug from time to time.
Some other long term effects of hallucinogens may be damaged memory and concentration. Using hallucinogens may increase the risk of mental problems in some people.
Hallucinogens and pregnancy
LSD may be related to an increased risk of miscarriage, but little is known about the effects of LSD in pregnancy.
Tolerance and dependence
Anyone can develop a 'tolerance' to hallucinogens. With hallucinogens this happens very quickly. Being tolerant to one kind of hallucinogen (e.g. LSD) can also make you tolerant to other kinds ('magic mushrooms'). Tolerance goes away while stopping the drug regularly.
There is little evidence that dependence or withdrawal syndromes exist for hallucinogens.
Hallucinogens and the law
Using, keeping, selling or giving hallucinogens to someone else is illegal. If you are caught you could get penalties starting from a $2 200 fine and/or two years in jail to a $550 000 fine and/or jail for life.
Treatment:
a) Hallucinogen intoxication:
Treatment of hallucinogen intoxication is the oral administration of 20 mg of diazepam. This medication brings the LSD experience and any associated panic to a halt within 20 mts.
b) Hallucinogen persisting disorder:
- Treatment for hallucinogen persisting disorder is palliative.
- The first approach in this disorder is correct identification of this disorder, pharmacological approaches include long- lasting benzodiazepines, such as long lasting benzodiazepines such as clonazepam, and to lesser extent, anticonvulsants including valproic acid and carbamazepine.
- Antipsychotic agents should only be used in the treatment of hallucinogen- induced psychoses, because they have a paradoxical effect and exacerbate symptoms.
- A second dimension of treatment is behavioural. The patient must be instructed to avoid gratuitous stimulation in the form of over- the counter drugs, caffeine and alcohol and avoidable physical and emotional stressors.
- Finally three co morbid conditions are associated with hallucinogen persisting perception disorder: panic disorder, major depression and alcohol dependence. All these conditions require primary prevention and early intervention.
c) Hallucinogen induced psychosis:
Treatment of hallucinogen induced psychosis does not differ from conventional treatment of psychoses. In addition to the antipsychotic medications, a number of agents are reportedly effective, including lithium carbonate, carbamazepine and electroconvulsive therapy. Antidepressant drugs, benzodiazepines and anticonvulsant agents may each have a role in the treatment as well
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