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complete absence of the drug. Flashbacks most often appear as visual symptoms and
can persist for months or in some cases years, and there appears to be no
relationship between frequency of hallucinogen use and rate of occurrence. Recently,
Halpern and Pope (2003) have reviewed the evidence on hallucinogen persisting
perception disorder (HPPD), the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition category for flashbacks. First, they note that the term
flashback itself has been defined in so many different ways that they believe it is now
virtually useless. Second, they point out that when LSD was used in a therapeutic or
research setting, HPPD appeared less frequently than when it was used
recreationally. Finally, because of the different ways that flashbacks were defined, it
is impossible to discern the true incidence of the disorder. They do conclude that at
least for some individuals, particularly users of LSD, a long-lasting HPPD syndrome
can occur with symptoms of "persistent perceptual abnormalities reminiscent of
acute intoxication." Based on the millions of people who have taken hallucinogens,
the incidence of HPPD appears to be very small, and there is presently no effective
treatment.
There are, however, real and significant dangers that can accompany recreational use
of these substances. Although LSD or other classical hallucinogens have not directly
caused overdose death, fatal accidents during LSD intoxication have occurred (Jaffe,
1985). This danger is significant, particularly when these drugs are used
recreationally in unsupervised settings. Belief that one has superhuman powers
while judgment is impaired by hallucinogens can lead to injury or death when an
unsupervised user carries out dangerous activities such as walking out on a freeway
or attempting to fly (see, e.g., Reynolds & Jindrich, 1985). Less serious but still very
substantial injuries can occur in unusual ways. For example, severe and irreversible
ocular damage has resulted from prolonged staring at the sun by individuals under
the influence of LSD (Schatz & Mendelblatt, 1973; Fuller, 1976).
The most significant dangers of psychedelics, however, appear to lie principally in
their psychological effects. LSD can induce disturbances of experience, otherwise
observed only in psychoses, such as alteration of cognitive functions, and
depersonalization. Hallucinogens can catalyze the onset of psychosis or depression,
which has sometimes led to suicide, and Cohen (1960) has estimated the incidence of
LSD-related psychosis to be about 8 per 10,000 subjects. In another study, one case
of psychosis was reported in a survey of 247 LSD users (McGlothlin & Arnold, 1971).
Fortunately, however, these drugs do not appear to produce illness de novo in
otherwise emotionally healthy persons, but these problems seem to be precipitated
in predisposed individuals.
In atypical courses of intoxication, so-called bad trips, anxiety and excitement
predominate. Bad trips can usually be treated successfully by "talk-down" therapy
and administration of benzodiazepines. In an early report, Taschner and Wanke
(1975) saw in their clinic several LSD users with psychoses. At the time, they
classified them into "flashbacks, exogenic (toxic) psychoses, and so-called endoform
psychoses." They considered three possible explanations for the latter category:
accidental coincidence of LSD use and onset of psychosis, preexisting psychosis with
symptomatic use of LSD as an attempt at self-treatment, or finally the onset of
psychosis triggered by the use of the hallucinogen. Based on the presenting
symptoms, these patients could not be reliably distinguished from real
schizophrenics.
A somewhat later study by Vardy and Kay (1983) compared patients hospitalized for
LSD psychosis with first-break schizophrenics. In most respects, the LSD psychotics
were fundamentally similar to schizophrenics in genealogy, phenomenology, and
course of illness. Their findings support a model of LSD psychosis as a druginduced
schizophreniform reaction in persons vulnerable to both substance abuse and
psychosis.
Although these studies demonstrate a significant danger of LSD use, the number of
such reports is very small relative to the numbers of persons who are believed to
have selfadministered LSD in recreational settings. A search of Medline in early 2003
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