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Introduction Intravenous ketamine, a dissociative anaesthetic, has been reported to alleviate major depression [1] and chronic pain [2] with minimal adverse effects [3,4], although perceptual disturbances are not uncommon [5]. Hallucinogen persisting perception disorder (HPPD)is an illness arising from the abuse of hallucinogens in which individuals suffer visual pseudohallucinations for months to years following exposure to LSD and similar drugs [6]. We now report a case of HPPD in a young man who received medically administered intravenous ketamine for treatment of a complex regional pain syndrome (CRPS). Case Report A 13 year old male piano student developed CRPS following a sacral injury. He had no history of substance use. At 15, chronic pain was treated with two continuous intravenous infusions of ketamine, each lasting a week, with maximal doses of 50 mg per hour. During each treatment he vomited and had visual and synesthetic hallucinations.Six months later he suffered the progressive onset of an array of visual pseudohallucinations and hypersensitivity to light and sound. Imagery included particles in the entire visual field seen in the air and on surfaces; large moving coloured blobs on surfaces; afterimages; trails of objects moving through his visual field, such as a tennis ball; objects changing their shape; and difficulty reading and playing the piano. He also suffered the incessant sensation of the euphoria he felt when given ketamine. These symptoms were reported as daily and constant on multiple follow-up visits over a three year period.A psychiatric evaluation found no evidence of psychosis or depression. The mental status examination confirmed a deficit in short term memory. The patient described continual visual disturbances during the examination. Reality testing was intact.There were no auditory hallucinations or delusions. Psychological testing confirmed a reading disorder. A quantitative EEG found evidence of an auditory processing disorder with irritability in the left temporal and occipital regions, including activation of the auditory system by visual stimuli, a putative marker for drug-induced synaesthesia.Medications including divalproex sodium, several SSRIs, gabapentin and pregabalin were unsuccessful. Lorazepam 2 mg twice daily reduced, but did not ablate, his symptoms for two months. In that time he returned to the piano and was admitted to a university music program. Relapse followed as the patient apparently developed tolerance to the treatment. A similar pattern followed use of diazepam10 mg a day. At the age of 18, he developed complex partial seizures which have been controlled with topiramate. However, the perceptual symptoms and ketamine euphoria have continued. Discussion and Conclusion Studies in subjects with HPPD suggest that the pathophysiology of the disorder involves either a slowly reversible or permanent disruption in the inhibition of visual information processing. This has been described from the use of LSD, MDMA, psychostimulants and a variety of botanical preparations of hallucinogens [7]. Evidence for visual disinhibition following LSD includes persisting after imagery [8],abnormal flicker fusion testing, impaired dark adaptation [9],electrophysiological measures of cortical disinhibition [10] and increased measures of cerebral coherence, a putative measure of increased cortical activation [11]. To the best of our knowledge this report is the first association between ketamine and HPPD.The mechanism by which ketamine antagonism of the NMDA receptor induces perceptual or psychotic symptoms is not known.Consistent in both animal and human studies, however, is the observation that ketamine increases activity of brain waves in the gamma (30 to 60 Hz) range. De la Salle et al. reported such an increase in gamma current density in the default mode network implicated ins chizophrenia, as well as activation of gamma frequencies across the cerebrum [12]. This finding supports a disinhibition model of HPPD.In addition, GABA-A agonists such as midazolam reduce HPPD symptoms [13].HPPD also appears to be associated with increased cerebral coherence, a measure of cortical connectivity [14]. Similarly, temporal lobe epilepsy involving the neocortex has been associated with increased coherence [15]. The role of ketamine in the generation or control of seizures is not known. But in our case, enhancement of cortical coherence with neurofeedback resulted in an exacerbation of HPPD.Ketamine, a schedule III drug which is an anaesthetic agent, can be prescribed by any physician. Enthusiasm for its use in treatment of refractory depression has yet to be tempered by a body of research establishing safety and efficacy [16]. The history of LSD in the 1960sfollowed such a course over time, in which a period of rising enthusiasm was followed by one of sober reconsideration as the risks and benefits were identified [17]. This report adds a note of caution to the process. https://www.longdom.org/open-access/hallucinogen-persisting-perception-disorder-following-therapeuticketamine-a-case-report-2329-6488-1000281.pdf hallucinogen-persisting-perception-disorder-following-therapeuticketamine-a-case-report-2329-6488-1000281.pdf

This is from a visual snow forum. "Sara took Klonopin for about 6 weeks in hopes of improving her visual disturbances. This was prescribed after we and her doctor had a phone consultation with Dr. Henry Abraham, the HPPD expert. He said about 50% of his patients visual disturbances disappeared after treatment with long-acting benzodiazepines like Klonopin or Valium" https://www.tapatalk.com/groups/thosewithvisualsnow/hppd-vs-visual-snow-validation-of-vs-t2332.html

I'll look around more when I have a moment but this is what showed up when I searched Dr. Abraham HPPD klonopin. "According to Abraham about half of those with HPPD will fully recover over five years. In addition, treating the comorbidities can actually help alleviate the core HPPD symptoms, since anxiety and depression appear to trigger the hallucinations. Benzodiazepines “can be helpful by reducing anxiety, which then decreases reactivity to environmental stimuli,” he noted. Clonazepam seems to be the most effective.6" https://www.neurologylive.com/view/when-partys-over-case-hppd Unfortunately HPPD is fairly rare disorder that most doctors aren't trained to treat so having studies to provide them with can only benefit the people on here. Also it gives some much needed hope. What did Dr. Abraham normally prescribe?

I found it mentioned in the article that rlopes posted. Included is why they thought the medication was helpful. "There is some evidence that anticonvulsive agents such as phenytoin, carbamazepine and valproic acid (Thurlow and Girvin, 1971; Abraham, 2000) may ameliorate this psychopathology, which may be interpreted as a ‘visual seizure’ (Thurlow and Girvin, 1971). Such an approach may help to explain the efficacy of benzodiazepines. Benzodiazepines seem to be the treatment of choice for the majority of patients (Abraham, 1983). They may improve, but not totally remove, this condition (Abraham et al., 1996). Among the wide range of available benzodiazepines, it is still unclear which of them may be more effective (Lerner et al., 2001)." Mind that Lerner said this a year before doing this study. "The effectiveness of benzodiazepine may be related to benzodiazepine activity at cortical serotonergic inhibitory interneurons with GABAergic outputs (Abraham and Aldridge, 1993; Abraham et al., 1996). Additional benefits regarding clonazepam may be proposed. There is a substantial amount of literature suggesting that clonazepam may affect serotonergic systems and that it may enhance serotonergic transmission (Bodkin and White, 1989; Hewlett et al., 1992). This may secondarily lead to down regulation of 5-HT2 receptors, which may contribute to the HPPD symptoms remission (Young, 1997). The specific serotonergic characteristics of clonazepam, along with its high potency, rapid rate of absorption and long lasting action, may play an important, although unclear role, in the observed improvement of the reported patients"

Appreciated and downloaded. This all looks really promising. I've taken Lamictal in the past and it definitely helps with minimal side effects. All of these studies and case reports seem to report otherwise. Whatever is the cause of HPPD, Klonopin appears to at the very least alleviate some of the symptoms permanently which is a god send. I've heard for a while that it possibly a seizure disorder and klonopin can help in that regard ( I believe this is discussed in one of the above studies ) so there is a possible link there.

This is case report shows clonazepam helping two people who developed HPPD from Synthetic Cannabis. Synthetic Cannabis Substances (SPS) Use and Hallucinogen Persisting Perception Disorder (HPPD): Two Case Reports "On psychiatric examination the patient reported visual occurrences which were similar to those experienced during SCS use and resembled intoxication-associated visual imagery. These almost daily episodes usually lasted between fractions of a second and a few minutes. The perceptual disturbances were sufficiently severe to cause significant distress, anxiety and impairment in social and occupational functioning. Mr. R fulfilled DSM-IV-TR diagnostic full criteria of HPPD (3). There was no previ-ous neurological, ophthalmological or other comorbid medical diseases or co-occurring psychiatric history. A complete physical, neurological (including EEG), and laboratory examination was unremarkable. Uncomplicated outpatient SCS withdrawal was unexpect-edly mild and was treated with small doses of clonazepam (5-8). Dosage started at 0.25 mg bid gradually increased to 1 mg bid after two weeks... His condition dramatically started to improve. He continued taking clonazepam 1mg bid for the next five weeks. After completing two months of treatment, he refused to continue pharmacological treatment stating that he does not need more “chemicals in his body.” He agreed to gradually stop clonazepam. After treatment suspension he continued to report considerable improvement in the frequency of perceptual disturbances and accompanying anxiety. At his six-month evaluation he reported that symptoms had disappeared almost completely. Despite the prominent amelioration, Mr. R continued to complain of focal visual disturbance known as trailing phenomena that remained without accompanying anxiety features." "On psychiatric evaluation Mr. B accurately recog-nized SCS as the precipitator of his condition (5-8). He reported that the panic attack was so distressing that SCS ingestion was immediately ceased. Disturbances were sufficiently severe to cause significant distress, anxiety and impairment in social and occupational functioning. He fulfilled DSM-IV-TR full criteria of HPPD (3). As in the case of R described above, all examinations revealed no abnormalities Uncomplicated outpatient SCS withdrawal was described as mild and treated with low doses of clonaz-epam, in a regimen described in the previous case. Mild anxiety features and sleep disturbances accompanied the withdrawal process. The patient was reluctant to be treated with “chemical drugs” (i.e., medications) and only accepted to take medication for a period of one month. He preferred to cope with his condition without medications, psychotherapy or counseling. Mr. B’s episodes of HPPD gradually became more benign and less distressing. His condition dramatically started to improve. After clonazepam suspension he continued to communicate a clear improvement in the frequency of perceptual disturbances. During the fol-lowing three months symptoms disappeared almost completely. At the end of six months an almost total absence of visual disturbances was reported. Despite the profound reported improvement, he continued to suffer from benign non-distressing perceptual disturbances characterized by black moving spots in his visual fields.DIscUssIONThough HPPD has been well-described and reviewed in the literature following use of various hallucinogenic substances (9), little is known about these phenomena following use of new “designer drugs.” Above we described two cases of HPPD following SCS use. While the exact subjacent mechanism of SCS associ-ated perceptual disturbances is largely unknown, there is some knowledge indicating similarities with those proposed mechanisms associated with the use of LSD (6) and NCS(1)." https://cdn.doctorsonly.co.il/2015/01/09_Synthetic-Cannabis.pdf https://www.researchgate.net/publication/281847744_Synthetic_Cannabis_Substances_SPS_Use_and_Hallucinogen_Persisting_Perception_Disorder_HPPD_Two_Case_Reports Synthetic Cannabis Substances (SPS) Use and Hallucinogen Persisting Perception Disorder (HPPD) Two Case Reports.pdf

The study that includes the two HPPD outpatients mentioned above isn't readily accessible online. I found the abstract and introduction though. "Benzodiazepines are recommended for the treatment of Hallucinogen Persisting Perception Disorder (HPPD), although it is unclear which may be more helpful. Two out-patients with LSD-induced HPPD were successfully treated with clonazepam. They had not responded to low potency benzodiazepines or low doses of classic antipsychotics. After clonazepam discontinuation they reported a marked improvement and only mild symptomatology which persisted during a six month follow-up period. High potency benzodiazepines like clonazepam, which has serotonergic properties, may be superior to low-potency benzodiazepines in the treatment of some patients with LSD-induced HPPD." https://search.proquest.com/openview/fc6d8758115dc39152bc59ddaf587dc6/1?pq-origsite=gscholar&cbl=47717 LSD-induced hallucinogen persisting perception disorder treated with clonazepam Two case reports.pdf

This paper includes a couple more cases where clonazepam helped as well as a few more cases where other medications either helped or potentially made symptoms worse. "An observational study recruited 21 HPPD subjects who were treated with benzodiazepines and/or phenothiazines (3). Among subjects receiving benzodiazepines, eight out of nine reported a reduction in intensity/frequency of visual disorders. Most (11 out of 12) phenothiazine-treated subjects described an exacerbation of HPPD (3)." "A study described two HPPD outpatients who efficaciously responded to clonazepam (25)." "An open-label study recruited 16 drug-free patients affected with HPPD with anxiety features for at least 3 months who received 2 mg daily of clonazepam for 2 months (27). Subjects reported a significant relief of anxiety and HPPD symptomatology with only mild symptomatology during the clonazepam treatment, suggesting the efficacy of clonazepam in these cases (27)" https://www.researchgate.net/publication/321166980_The_Endless_Trip_among_the_NPS_Users_Psychopathology_and_Psychopharmacology_in_the_Hallucinogen-Persisting_Perception_Disorder_A_Systematic_Review/fulltext/5a12d25c4585158aa3e1bb29/The-Endless-Trip-among-the-NPS-Users-Psychopathology-and-Psychopharmacology-in-the-Hallucinogen-Persisting-Perception-Disorder-A-Systematic-Review.pdf#page=1&zoom=auto,-406,786 https://www.frontiersin.org/articles/10.3389/fpsyt.2017.00240/full The “Endless Trip” among the NPS Users Psychopathology and Psychopharmacology in the Hallucinogen-Persisting Perception Disorder. A Systematic Review.pdf

Found a case report that states a person had it for 25 years and was mostly symptom free 3 months after being prescribed Clonazepam 1 mg four times. 8 of the 9 listed symptoms were absent and the one that was still present, Halos around objects, was reduced in intensity and frequency. " A forty-eight year old man presented with unusual and distressing visual experiences with varying degrees of severity for over twenty years. Some of these included the following; red objects having a green shimmer around them like 3-D glasses, altered sense for distance estimation, people’s faces seeming to change shape when looked at, alteration of own reflection, anything patterned appearing to move all the time, words moving about while reading, things appearing to be multi-layered, bright lights throwing up shadows, vehicles appearing to stretch as they drive past, flying birds looking like animation and difficulty in focusing. When present, his symptoms interfered markedly with his functioning. For example, he could not cross the road, could not read, and had to dim his lights. He struggled with knowing which visual perceptions were real and which were not. The patient felt his visual experiences were related to his past LSD use twenty-five years ago. He felt the drug had put him “in a coma” and he was “dreaming all of this”. " "His other complaint was that of feeling he was “not real”; to the extent he even thought he should harm his family members so he could prove he was real. He also complained of low mood, decreased concentration, anxiety and an inability to cope. His first contact with mental health services was at the age twenty two years. He presented with symptoms of anxiety but it was not felt he had a mental illness. He was referred again a year later and was diagnosed to have Primary Depersonalization syndrome. The patient himself reported that all his symptoms started after he had used LSD about fifteen times in six months. At the time he had described having undergone a complete personality change due to his experiences. He felt objects and experiences had a dream-like quality. His visual experiences caused so much distress he felt suicidal." "Investigations: EEG, MRI Brain, and Carotid ultrasound were normal." "He was admitted to a psychiatric hospital at the age of forty-eight years old where the admitting doctor described his symptoms as visual hallucinations and started him on Risperidone, which increased the intensity of his symptoms. He was also treated with Citalopram for his low mood. It was noted that his symptoms were different from common psychotic illnesses. Detailed history taking and assessment of his perceptual abnormalities over the following few weeks in hospital confirmed the diagnosis of hallucinogen persisting perception disorder (HPPD). He was treated with Clonazepam 1 mg four times a day with good effect; as seen by the reduction of symptoms" "There have been some published case reports on treatment of HPPD, including the use of Reboxetine, which suggest it is beneficial in the treatment of the visual disturbances and depressive features associated with HPPD. This is possibly due to its alpha 2 adrenoceptor modulating effect on both Noradrenaline and Serotonin release8. Another case report suggested the use of a combination of Fluoxetine and Olanzapine in the treatment of HPPD9." https://www.bjmp.org/content/25-years-hallucinogen-persisting-perception-disorder-diagnostic-challenge 25 years of Hallucinogen Persisting Perception Disorder- A diagnostic challenge.pdf

So I did some digging around to try and find more information on this study. Unfortunately, it's locked behind paywalls so I requested access from the author and hopefully they will come through. It is mentioned in another paper though that sheds a little bit more light on the study. "Clonazepam has been evaluated in three case reports and one open-label trial by Lerner [19,50,51]. In the clinical trial, 16 HPPD patients were treated with a Clonazepam dosage of 2 mg/day [51]. Their symptoms improved significantly after treatment initiation and the improvement persisted during a 6-month follow-up after treatment discontinuation [51]. The same author reported two cases of cannabis-induced visual disturbances and correlated anxiety features. In both cases, Clonazepam (2 mg/day) was effective in improving symptoms, but focal visual disturbances without anxiety (trailing phenomena in one case, and black moving spots in the second case) persisted during and after therapy [19]. More recently, Clonazepam (6 mg/day) has been proved to be effective in improving cannabis-induced HPPD symptoms [50]. On the other hand, the intrinsic abuse potential of benzodiazepines might be inconvenient in certain individuals with a past history of substance use [17,18]. Given the benign nature of HPPD I, the use of benzodiazepines should be proposed only for severe cases, in the acute phase, and for the short term." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5870365/ Hallucinogen Persisting Perception Disorder Etiology, Clinical Features, and Therapeutic Perspectives.pdf

Correct me if I'm wrong, but that sounds like the participants took the clonazepan for 2 months, not 6. Can anyone clarify if this means that they stopped taking the clonazepan and they continued to maintain the improvement seen while taken the medication?

You need help. Are you seeing a counselor? Psychiatrist?

Try asking your dr for a beta blocker

Yes, it is possible to have both. Typically when someone has a mental disorder they have a few others. For example, I'm dealing with ocd, depression and general anxiety. These are a few of the most common physical symptoms of depression: Increased aches and pains, which occur in about two out of three people with depression. Chronic fatigue. Decreased interest in sex. Decreased appetite. Insomnia, lack of deep sleep, or oversleeping. https://www.google.com/search?q=physical+effects+of+depression&ie=utf-8&oe=utf-8 Common physical symptoms of anxiety include: Pounding heart Sweating Stomach upset or dizziness Frequent urination or diarrhea Shortness of breath Tremors and twitches Muscle tension Headaches Fatigue Insomnia http://www.helpguide.org/articles/anxiety/anxiety-attacks-and-anxiety-disorders.htm