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Early writings... part of a 20 page attack on the diagnosis

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The American Psychiatric Association produced the DSM-IV with minimal (get citation, and the exact number of studies) empirical research to evaluate the validity of a diagnosis. The limited research conducted focused on measuring and demonstrating inter-rater reliability for a diagnosis. The result was a sacrifice of validity for reliability. With the exception of stating HPPD is a transient disorder, the subjective perceptual experiences of Hallucinogen Persisting Perception Disorder (Flashbacks) are so broadly defined the clinician is to make a judgment about the symptoms and their qualification as similar to hallucinogenic experience. The disorder criteria is absent of items that did exist in the literature (Abraham, 1983) to create a detailed characterization of symptoms required for chronic HPPD, or a description discussion of symptom severity (e.g. inability to drive at night, color impairment), and recognize the critical distinguishing features between these form experienced as differences in frequency and duration of symptoms.

In theory, a patient experiencing transient derealization and distorted reality for a ten minute flashback that occurs a few times a year would be clinically identical as a diagnosis to a patient with chronic, unremitting, constellation of altered visual perception, which potentially has lasted for 20 or more years. Case report failing to identify the symptoms and only list the disorder of HPPD is valueless when the patient could be on either end of the spectrum and from the text indistinguishable and similarly diagnosed as HPPD. A clinician listing HPPD as a diagnosis on a patient chart or in a published report affords a reviewer very little except hoping the report paints a detailed presentation of symptoms. The challenge for reviewers seeking evidence based on case reports is the absence of these details. Simply stating the diagnosis without addition information contributes to confusing and diluted literature.


Criterion A includes a few symptom examples exempli gratia of potential perceptual disturbances, but these are neither required nor discussed in the text any further. These examples are taken from Abraham’s (1983) seminal work on HPPD that defined 10 specific symptoms with descriptions from a population of 123 LSD users with lasting perceptual alterations. The chronic form of the disorder is essentially excluded from fitting this strict definition as "transient".

Chronic HPPD is observed as the most clinically distressful form of HPPD, and pharmacological treatments for Flashback type are not the same as those for chronic HPPD..{{2288 Strassman 1984;}} describes the disorder’s severity based on temporal experience: “responses to the use of these drugs, sometimes require careful clinical judgment in order to diagnose. These reactions can be effectively classified along a temporal continuum. Acute, short-lived reactions are often fairly benign, whereas chronic, unremitting courses carry a poor prognosis.” Additionally, numerous authors have stated the disorder consists of two distinct entities (Abraham, 1983; Abraham & Aldridge, 1993; Abraham, Aldridge, & Gogia, 1996; Lerner et al., 2002; Lerner et al., 2003). Lerner (2003) provides further clarification of this disorder:

“At least two subtypes of this syndrome have been reported (Lerner et al., 2000). The first is a transient, recurrent, spontaneous, reversible and generally visual benign experience. Experienced LSD users generally look at these recurrences as a ‘free trip’, an aspect of the psychedelic dimension, and do not seek psychiatric assistance after experiencing this kind of episodes. The second is hallucinogen persisting perception disorder (HPPD). This is long-term, spontaneous, intermittent or continuous, pervasive and either slowly reversible or irreversible. This phenomenon is entirely different from the benign ‘flashback’.”

Henry David Abraham, M.D. is the first to characterize the disorder and served on the Advisory Board, DSM Work Group on Alcohol and Substance Abuse, Committee to Revise DSM-IV, in 1986 and earlier the Committee to Revise DSM-III. Widely considered the leading expert on HPPD, he has authored numerous book chapters on hallucinogen-related disorders, including two widely used texts of Psychiatry including [Cite Tassmen and Current Opionions] and includes these subtypes as distinct entities. Despite Dr. Abraham’s position on the committees addressing HPPD, the criteria fail to match the literature and reality. Why did this patient population become forgotten in the language of the diagnosis? Historically, the creation of the diagnosis was described as flashbacks, and even now the term flashbacks are used to address HPPD. Not addressing this form explicitly denies the evidence and reduces the clinical utility of this diagnosis. The common understanding of the disorder has resulted in a reluctance to address the chronic form directly, and to continue to bundle Flashbacks with a disorder that is contstant and unremitting, and in many cases is a life-long condition.

The development of diagnosis over time: Flashback came first.

The earliest account of a hallucinogen-induced persisting affect was presented in Ellis (1898); as cited in Halpern & Pope, 2002, who reported a prolonged sensitization, to ‘‘the more delicate phenomena of light and shade and color’.’(Barron, Lowinger, & Ebner, 1970; Cooper, 1955; Favazza & Domino, 1969; Horowitz, 1969; Woody, 1971) were first to address LSD-induced pathology, and Horowitz (1969) is associated with the popular adoption of the term “LSD Flashback” to describe any recurring pathological condition from LSD. The name proved attractive, and was adopted by the drug culture and popular media. The branding of the disorder remains today in the name of the diagnosis despite the confusion this creates for someone trying to understand the HPPD condition. The disorder had no formal diagnosis until 1986, when the American Psychiatric Association’s (American Psychiatric Association, 1986) publication of the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), defined the diagnostic criteria for ‘flashbacks’ under the diagnosis of ‘Posthallucinogen perception disorder’. These criteria were slightly modified for the DSM-IV (American Psychiatric Association, 1994) and renamed Hallucinogen Persisting Perception Disorder (Flashbacks); the former diagnostic name is still used even today (Buzzed by Kuhn and friends, cite).

The HPPD diagnosis does not contribute to better conceptualization of the condition or to better assessment and treatment)

The goal is that the classification system used matches what exists in nature, which contains the power to predict the maximum possible number of facts that can be gleaned to understand a patient diagnosed with a specific disorder. Relying on the DSM-IV-TR for diagnostic information relies heavily on the clinician’s interpretation of this disorder, their knowledge of the literature or experience, and a patient’s self-report for accurate diagnosis. A clinician or researcher seeking additional information will likely find the first barrier to understanding the disorder at the point of the diagnosis name: Chronic HPPD is not equivalent to flashbacks, and this lingering language used both by researchers and hallucinogen users. The word flashback does not clarify the diagnosis; it simply blurs the boundaries of two different disorders, and expands the range sufficient to meet the threshold for an HPPD diagnosis..

A disorder without precision, characterization, and distinction of two different disorders, each proposed to have distinct etiology, produces an unacceptable high degree of diagnostic errors. On average, Dr. Abraham stated that a person with chronic HPPD will see six different clinicians until receiving the appropriate diagnosis (Personal Communication; www.drabraham.com). The diagnostic language results in clinical errors, miscommunicated research, and ultimately a suffering patient.

. The language and criteria in the DSM-IV-TR HPPD diagnosis lacks construct validity, the pairing of criteria and what (Kaplan and sadock's comprehensive textbook of psychiatry (2 volume set) 2009) stated as “experimental confirmation of hypotheses concerning the etiology and pathophysiology of an illness construct, demonstrating that the category represents a real and natural occurring entity with a specific pathological mechanism.” The current HPPD diagnosis lacks validity and consequently results in value-reduced research and poorer patient care and clinical reports.

The key concept for evaluating a diagnosis is to determine if the symptoms experienced are represented in the diagnosis. This is a measure of construct validity, the ideal standard for creating independent measurable elements of a diagnosis for often immeasurable experiences and symptoms to form an accurate diagnostic validity. Construct validity is the “experimental confirmation of hypotheses concerning the etiology and pathophysiology of an illness construct, demonstrating that the category represents a real and natural occurring entity with a specific pathological mechanism.”(Cite Text)

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