Therapy of HPPD

The most important thing for the HPPD sufferer is to avoid further use or abuse of psychoactive substances, and, therefore, drug rehabilitation therapy is an important factor in coping with the disorder. Based on his own experience, one HPPD sufferer noted "that if you quit tripping I believe that these things do subside to a certain extent and with time... mind is healing...", a good prognosis that can be achieved with greater probability if one sticks to drug abstinence.

(Andrew [subject #99], Email to Klaus Podoll, May 11, 2006)

Just as in management of persistent aura without infarction (see here), the currently available recommendations for pharmacotherapy of HPPD can only be based on type IV of evidence according to Clancy (1997), i.e. evidence obtained from opinions and/or clinical experiences of respected authors. Well-designed controlled therapy studies and randomized controlled trials have yet to be done.

Abraham's (1983) classical paper on visual phenomenology of the LSD flashback described HPPD as a disorder "treatable with benzodiazepines". One study suggests that high potency benzodiazepines like clonazepam, which has serotonergic properties, may be more effective than low-potency benzodiazepines in the treatment of some HPPD patients (Lerner et al., 2003). Overall, pharmacological agents such as clonazepan (Lerner et al., 2001), clonidine (Lerner et al., 1998; Lerner et al., 2000) and perphenazine (Lerner et al., 2002a) have been shown to ameliorate this syndrome in some of the individuals seeking treatment (for a review see Abraham et al., 1996, and (Lerner et al., 2002a).

A case report on a patient with comorbidity of HPPD and major depressive episode documented successful treatment with reboxetine (Lerner et al., 2002b), a norepinephrine reuptake inhibitor (NRI). Young (1997) reported successful treatment of a HPPD patient with sertraline, an antidepressant of the selective serotonin reuptake inhibitor (SSRI) type. A patient from Aldurra and Crayton (2001) showed improvement of HPPD by treatment with a combination of fluoxetine (another antidepressant of SSRI type) and olanzapine (an atypical antipsychotic).

An expert's recommendation for pharmacological treatment of HPPD

According to Dr. Arturo Lerner, Chief Psychiatrist in the Rehab Ward, Lev HaSharon Mental Health Center, affiliated to the Sacker School of Medicine, Natanya, 42100, Israel, "The election of the treatment of HPPD depends on the clinical picture. HPPD without anxiety or depression can be treated with perphenazine (up to 8 mg/day, bed time dose), HPPD with anxiety with clonazepam (up to 2-4 mg/day, three times dose), HPPD with depressive features with citalopram (up tp 40 mg/day, bed time dose) and in some cases with venlafaxine (up tp 225 mg/day, one increasing morning dose), HPPD with mood swings with lamotrigine (up to 200 mg/day, increasing 25 mg every two weeks from a starting dose of 25 mg/day). These clinical advises are results of my clinical observations only. They are not based on research."

(Dr. Arturo Lerner, Email to Larry [subject #32], August 11, 2006)

Clonazepam is considered by most experts as the medication of first choice with a diagnosis of HPPD, though possible side effects and risks including benzodiazepine dependence have to be carefully considered before starting a trial with clonazepam (cf. The Ashton Manual for more information on benzodiazepine addiction, withdrawal and recovery).

One HPPD sufferer (subject #191) described the effects of the high potency benzodiazepine thus:

"Recently I have started taking Klonopin (clonazepam), 5 mg 3 times daily... My vision has never been better! I can barely notice it during the day; I mean it is very, very faint and slow. I give it about an 85 % reduction in intensity. In the dark it just appears as a very faint mist. There are no more color outbursts, tracers, shimmering, depersonalization, anxiety, supermarket phenomenon and driving in the rain appears to be as normal as prior to symptom onset. Driving at night is o.k. I cannot even notice the snow anymore. It does not bother me one bit and I think I had some of the worst symptoms of HPPD or Visual Snow."

(Scoe99 [subject #191], Ezboard forum Visual snow or static – Discussion - Good news from Scoe99, April 12, 2004)

Unfortunately, such good response (if present) is not always lasting, as illustrated by the following case recorded at the Ezboard forum Visual snow or static:

"lysergium thought he was getting better with klonopin and he stayed off the board for a long time prompting us to hope that he actually did get better. But then he's also back on the board saying klonopin does not help him anymore."

(sand500, Ezboard forum Visual snow or static – Discussion – RE, April 25, 2005, 2006)

Anti-psychotics such as phenothiaziones (Abraham, 1983) or risperidone (Abraham and Mamen, 1996; Morehead, 1997) have sometimes been given but should be avoided since they can make HPPD much worse, the patients showing an exacerbation of LSD-like panic and visual symptoms. Thus, HPPD may be a relative contraindication for the use of these types of neuroleptic drugs.

The lack of effective psychopharmacological treatment means that many sufferers simply have to learn how to cope with HPPD. Some users find that counselling or psychotherapy can be useful in reducing the impact of the visual effects on their life. Psychotherapy may help patients adjust to the confusion associated with visual distraction and to minimize the fear, expressed by some, that they are suffering brain damage or insanity.

References

Abraham HD. Visual phenomenology of the LSD flashback. Arch Gen Psychiatry 1983; 40: 884-889. [PDF]
Abraham HD, Mamen A. LSD-like panic from risperidone in post-LSD visual disorder. J Clin Psychopharmacol 1996; 16: 238-241. [PDF]
Abraham HD, Aldridge AM, Gogia P. The psychopharmacology of hallucinogens.
Neuropsychopharmacology 1996; 14: 285-298. [PDF]
Aldurra G, Crayton JW. Improvement of hallucinogen persisting perception disorder by treatment with a combination of fluoxetine and olanzapine: case report. J Clin Psychopharmacol 2001; 21: 343-344.
Ashton CH. Benzodiazepines - How They Work and How to Withdraw. Updated version January 2007 (order here; the previous version from August 2002 is available for free here)
Clancy CM. Ensuring health care quality: an AHCPR perspective. Agency for health care policy and research. Clin Ther 1997; 19: 1564-1571.
Lauterbach EC, Abdelhamid A, Annandale JB. Posthallucinogen-like visual illusions (palinopsia) with risperidone in a patient without previous hallucinogen exposure: possible relation to serotonin 5HT2a receptor blockade. Pharmacopsychiatry 2000; 33: 38-41.
Lerner AG, Finkel B, Oyffe I, Merenzon I, Sigal M. Clonidine treatment for hallucinogen persisting perception disorder. Am J Psychiatry 1998; 155: 1460.
Lerner AG, Gelkopf M, Oyffe I, Finkel B, Katz S, Sigal M, Weizman A. LSD-induced hallucinogen persisting perception disorder treatment with clonidine: an open pilot study. Int Clin Psychopharmacol 2000; 15: 35-37.
Lerner AG, Kladman I, Kodesh A, Sigal M, Shufman E. LSD-induced Hallucinogen Persisting Perception Disorder treated with clonazepam: two case reports. Isr J Psychiatry Relat Sci 2001; 38: 133-136.
Lerner AG, Gelkopf M, Skladman, Oyffe L, Finkel B, Sigal M, Weizman A. Flashback and Hallucinogen Persisting Perception Disorder: clinical aspects and pharmacological treatment approach. Isr J Psychiatry Relat Sci 2002a; 39: 92-99.
Lerner AG, Shufman E, Kodesh A, Kretzmer G, Sigal M. LSD-induced Hallucinogen Persisting Perception Disorder with depressive features treated with reboxetine: case report. Isr J Psychiatry Relat Sci 2002b; 39: 100-103.
Lerner AG, Gelkopf M, Skladman, Rudinski D, Nachshon H, Bleich A. Clonazepam treatment of lysergic acid diethylamide-induced hallucinogen persisting perception disorder with anxiety features. Int Clin Psychopharmacol 2003; 18: 101-105.
Morehead DB. Exacerbation of hallucinogen-persisting perception disorder with risperidone. J Clin Psychopharmacol 1997; 17: 327-328.
Young CR. Sertraline treatment of hallucinogen persisting perception disorder. J Clin Psychiatry 1997; 58: 85.