HPPD diagnostic criteria - video

[Ghormeh Sabzi]

This was posted by someone on the visual snow forum:

http://www.youtube.com/watch?v=SpE4YB7YBTs

Thoughts?

[alice-acid]

wait so according to the DSM IV explaination any of the visuals we get that we didnt have whilst tripping arent technically hppd?

i didnt have most of them when i was tripping e.g -

after images, palinopsia(closed eyes after images images?), starbursts, visual snow, ETC

so that would mean me and everyone on this forum that experience these symptoms and others that arents specific visuals they saw DURING thier trip cant say these symptoms are because of HPPD?

which would mean the term HPPD is used incorrectly by the people that diagnose us with it and us

but, flashbacks by definition are temporary, and hppd by definition is ongoing (hallucinagen persisiting perseptive disorder)

thats absolutely rediculous

but has left me utterly confsued... so do we technically not have hppd? we just all have the same 'inert drug here' unclassified visual disturbances or whatever they called it?

this is rediculous their definition of HPPD contradicts itself |:

the odd thing i find is that all the symptoms are there, but we had to have had these symptoms during the trip for it to be hppd, even though most of us didnt?

here it is in writing BTW

Excerpt from the DSM-IV, p232-233:

292.89 Hallucinogen Persisting Perception Disorder (Flashbacks)

The essential feature of Hallucinogen Persisting Perception Disorder (Flashbacks) is the transient recurrence of disturbances in perception that are reminiscent of those experienced during one or more earlier Hallucinogen Intoxications. The person must have had no recent Hallucinogen Intoxication and must show no current drug toxicity (Criterion A). This re-experiencing of perceptual symptoms causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion . The symptoms are not due to a general medical condition (e.g., anatomical lesions and infections of the brain or visual epilepsies) and are not better accounted for by another mental disorder (e.g., delirium, dementia, or Schizophrenia) or by hypnopompic hallucinations (Criterion C). The perceptual disturbances may include geometric forms, peripheral-field images, flashes of color, intensified colors, trailing images (images left suspended in the path of a moving object as seen in stroboscopic photography), perceptions of entire objects, afterimages (a same-colored or complementary-colored "shadow" of an object remaining after the removal of the object), halos around objects, macropsia, and micropsia. The abnormal perceptions that are associated with Hallucinogen Persisting Perception Disorder occur episodically and may be self-induced (e.g., by thinking about them) or triggered by entry into a dark environment, various drugs, anxiety or fatigue, or other stressors. The episodes may abate after several months, but many persons report persisting episodes for 5 years or longer. Reality testing remains intact (i.e., the person realizes that the perception is a drug effect and does not represent external reality). In contrast, if the person has a delusional interpretation concerning the etiology of the perceptual disturbance, the appropriate diagnosis would be Psychotic Disorder Not Otherwise Specified.

Diagnostic criteria for 292.89 Hallucinogen Persisting Perception Disorder (Flashbacks):

A. The re-experiencing, following cessation of use of a hallucinogen, of one or more of the perceptual symptoms that were experienced while intoxicated with the hallucinogen (e.g., geometric hallucinations, false perceptions of movement in the peripheral visual fields, flashes of colors, intensified colors, trails of images of moving objects, positive afterimages, halos around objects, macropsia, and micropsia.

B. The symptoms in Criterion A cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The symptoms are not due to a general medical condition (e.g., anatomical lesions and infections of the brain, visual epilepsies) and are not better accounted for another mental disorder (e.g., delirium, dementia, Schizophrenia) or hypnopompic hallucinations.

[alice-acid]

with the word transient in it (Lasting only for a short time; impermanent) and the phrase 'recurrence of disturbances in perception that are reminiscent of those experienced during one or more earlier Hallucinogen Intoxications' means that what we all have is not HPPD?!?!?!?!?!?!?!?!?!?!?!

[alice-acid]

i dont understand why noone else finds this interesting lol

[Still_here]

I know my viuals arent what I saw on acid or the raft of other drugs I used. To be honest Im kinda glad HPPD is nothing like psychadelics were for me, the drugs were WAY more intense, HPPD (or whatever I have) is still a bitch though!

Dont know what to make of this guy, I think that if they came up with a name for what we have (cause I know I sure as hell dont have the "Cannabis disorder, not otherwise specified") most people would have that, rather than HPPD.

Does this guy have HPPD, cause if he doesnt I think he should f*** off and find something else to be a cock about.

[Shannondances]

I feel like medical books aren't even the greatest even thought they are approved... by who? but anyway new shit comes out every day and new drugs are tried every day you cannot tell me that everything in the book is right. We tend to get things wrong.

[David S. Kozin]

Here is a response to this from a very rough draft of my text (it contains sections from multiple chapters lumped into this)

INTRODUCTION

Creating a diagnosis that accurately represents clinical reality will remain an elusive goal. However, even in imperfect form, a universal diagnostic classification for mental disorders is necessary for epidemiological research, promoting a common language for communicating psychopathology, and for insurer and social services to determine who receives medical intervention. Nosology, the study and practice of classification in medicine, is a dynamic process that evolves as research contributes new techniques and theories to understand psychiatric disorders.

Ideally, clinicians would be aware of critical research findings, and command a current understanding of mental disorders to justify and inform their methods and basis for diagnosis and treatment. Realistically, clinicians are unable to study the wide spectrum of disorders receiving updated findings from the many disciplines contributing to the understanding of mental disorders. The American Psychiatric Association (APA) publishes the Diagnostic and Statistical Manual of Mental Disorders, developed by specialists in their field to synthesize and condense the recent state of research into useable diagnostic entities, and provides descriptive text of critical information to guide clinicians to make informed decisions. The current DSM-IV has been criticized by clinicians for not capturing the clinical complexities of many of their patients (Spiegel, 2010). The diagnosis for Hallucinogen Persisting Perception Disorder (Flashbacks) lacks clinical utility to truly capture the disorder as experienced in clinical practice.

THE HPPD DIAGNOSIS FAILS TO DEFINE OBSERVED DIAGNOSTIC BOUNDARIES.

Hallucinogen Persisting Perception Disorder (Flashbacks), or HPPD, is characterized by a person continuously experiencing altered visual perception after using a hallucinogen with symptoms resembling the hallucinogen experience. In descriptive text accompanying the diagnostic criteria for HPPD , the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision, (DSM-IV-TR; American Psychiatric Association, 2000), states “[HPPD’s] essential feature … is transient recurrence of disturbances in perception that are reminiscent of those experienced during one or more earlier Hallucinogen Intoxications.” This descriptive text does not discuss the two distinct disorders represented in case reports, clinical experience, and presented in the literature. The disorder is identified as a “transient” recurrence, and the text fails to provide comments on the chronic form despite the presence of this form in clinical literature for almost a decade prior to the publication of the latest version of the DSM. The population of chronic HPPD sufferers are the most clinically distressed, most likely to seek medical help, and individuals with the continuous form are often frustrated with clinicians not appreciating the reality of their disorder. This experience is a true flashback, which is often the least distressful type of HPPD, yet receives the manual’s attention. The complete diagnostic criteria in the DSM-IV-TR is:

Hallucinogen Persisting Perception Disorder (Flashbacks)

Diagnostic Code: 292.89

The essential feature of Hallucinogen Persisting Perception Disorder (Flashbacks) is the transient recurrence of disturbances in perception that are reminiscent of those experienced during one or more earlier Hallucinogen Intoxications. The person must have had no recent Hallucinogen Intoxication and must show no current drug toxicity (Criterion A). This re-experiencing of perceptual symptoms causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion . The symptoms are not due to a general medical condition (e.g., anatomical lesions and infections of the brain or visual epilepsies) and are not better accounted for by another mental disorder (e.g., delirium, dementia, or Schizophrenia) or by hypnopompic hallucinations (Criterion C). The perceptual disturbances may include geometric forms, peripheral field images, flashes of color, intensified colors, trailing images (images left suspended in the path of a moving object as seen in stroboscopic photography), perceptions of entire objects, afterimages (a same-colored or complementary-colored "shadow" of an object remaining after the removal of the object), halos around objects, macropsia, and micropsia. The abnormal perceptions that are associated with Hallucinogen Persisting Perception Disorder occur episodically and may be self-induced (e.g., by thinking about them) or triggered by entry into a dark environment, various drugs, anxiety or fatigue or other stressors. The episodes may abate after several months, but many persons report persisting episodes for 5 years or longer. Reality testing remains intact (i.e., the person realizes that the perception is a drug effect and does not represent external reality). In contrast, if the person has a delusional interpretation concerning the etiology of the perceptual disturbance, the appropriate diagnosis would be Psychotic Disorder Not Otherwise Specified.

Diagnostic criteria for Hallucinogen Persisting Perception Disorder

A. The re-experiencing, following cessation of use of a hallucinogen, of one or more of the perceptual symptoms that were experienced while intoxicated with the hallucinogen (e.g., geometric hallucinations, false perceptions of movement in the peripheral visual fields, flashes of colors, intensified colors, trails of images of moving objects, positive afterimages, halos around objects, macropsia, and micropsia.)

B. The symptoms in Criterion A cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The symptoms are not due to a general medical condition (e.g., anatomical lesions and infections of the brain, visual epilepsies) and are not better accounted for another mental disorder (e.g., delirium, dementia, Schizophrenia) or hypnopompic hallucinations.

(Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000) Reprinted as fair use for academic purpose.

The American Psychiatric Association produced the DSM-IV with minimal 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.

LACK OF SPECIFICITY

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.

Chronic HPPD is observed as the most clinically distressful, and pharmacological treatments for Flashbacks 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)

The HPPD Chronic Symptoms Experienced in Clinical Settings.

.

The HPPD diagnosis lacks a structured diagnostic instrument to aid in diagnosing or determine the severity of the disorder. Unlike other disorders where well-known self-report questionnaires exist to evaluate the severity of symptoms – symptoms of dissociation have the Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986) and the Dissociation Questionnaire (DIS-Q; Vanderlinden, 1993) – the HPPD diagnosis is applied predominantly on the subjective self-report of patient description of their perceptual experience of an event traced back to the event of hallucinogen intoxication. The range of altered experiences during hallucinogen intoxication is beyond the scope of this paper. Consequently, HPPD is a diagnostic entity based entirely on the self-report and clinical judgment resulting in poorly defined boundaries.

Does HPPD indeed only manifest in psychological variables, or is some manifestation of the disorder measurable such that it belongs in the realm of neurological disorders At the time of its introduction, there was far less interest in the diagnosis as there is now. The resurgence of psychedelic research has made understanding the risks of hallucinogens paramount to reduce risk to the participant.

Lacking specificity in the disorder allows an individual experiencing both transient recurrences of disturbances reminiscent of those experienced during one or earlier hallucinogen intoxications and individuals who experience continuous, unremitting, perceptual disturbances that can last throughout one’s life. A diagnostic instrument would help clarify which symptoms are experienced, evaluate the severity and validate the diagnosis of the disorder. Currently, the diagnostic criteria do not require an individual to fulfill a number of empirically derived factors, but simply fulfill the basic recurrence of hallucinogenic experience. This lack of specificity has resulted in misdiagnosis, improper treatments, and hampered research.

Subjects who are receiving an inaccurate diagnosis or no detection/no diagnosis in clinical settings, or who are not presenting for treatment because there is a lack of public awareness that the symptoms represent a valid entity.

The research and clinical community must not hinder the ability for the disciplines to communicate common symptoms in the same language. This would particularly aid Internet searchers where keywords are used for developing relationships between articles. {{2206 Kawasaki,A. 1996}}reports three clinical cases of HPPD patients in the Archives of Ophthalmology, and offers one common explanation for the lack of knowledge diagnosing HPPD patients in this discipline: 1) Palinopsia (and the trailing variant) as a symptom of hallucinogen use is not present in the neurologic or ophthalmologic literature. The only notable case in ophthalmologic literature reporting visual illusions from hallucinogen use were Levi and Miller (1990). {{2206 Kawasaki,A. 1996}}argues, “palinopsia, as well as other chronic visual disturbances from LSD, has been well detailed in the psychiatric literature… One possible reason for this discrepancy may be differences in descriptive terminology. Psychiatrists do not use the term palinopsia; instead, they refer to this symptom as ‘afterimagery’ or ‘visual flashbacks.’”

The current diagnosis results in harm to affected.

HPPD’s FAILURES IN THE DSM-IV: THE DSM-V AND BEYOND A CHANCE TO IMPROVE?

The American Psychiatric Association Task Force in charge of developing the DSM-V is approaching the development of this revision carefully. The expected date for publication has been pushed back to 2014. The APA Task Force has made this process public with a web site posting periodic updates from conferences, research, and meetings. The DSM5.org web site updates revisions for each diagnosis, and the web site also serves to support conducting large studies for multisite trials to develop valid constructs.

From the onset, the APA laid out clear goals: encourage large clinical trials focused on research to increase clinical validity, maintain a level of simplicity, and when possible include dimensionality. Dimensionality, the inclusion of rating scales as part of the diagnosis, is a popular notion with researchers and clinicians who have invested in developing psychometric instruments based on dimensional scales in research and practice. Dimensional scales allow for measurements along a spectrum. This improvement provides the inclusion of ratings for variables including symptom severity, duration, and frequency. Alone, this change would drastically improve the precision of the diagnosis involving validated scaled currently in research.

Additionally, including a cumulative list of symptoms with improved description instead of the broad definitions would allow for a diagnosis to be decided on a more specific set of criteria, where substitution and weighting of symptoms provide increased diagnostic leeway.

Dr. David Spiegel (presentation, ISSTD conference) discussed the categorical system established in DSM-III, -III-R, and –IV and stated the diagnostic criteria had attained acceptable levels of reliability. However, he admits that epidemiological, neurobiological, cross-cultural, and basic behavioral research conducted since the DSM-IV’s adoption suggests demonstrating construct validity for many of these diagnostic entities as envisioned by Robins and Guze (1970) is expected to remain an “elusive goal” in this version of the manual.

Adding dimensionality and increased specificity to the DSM-V will better enable clinicians to document the clinical status of their patients, and hopefully complementing and stimulate further research.

The HPPD diagnosis utility was severely diminished with an absence of specific scales for symptom frequency, duration, and without characterization or descriptions. Reviewing the literature for articles on HPPD results in the reviewer dismissing many articles for lack of confirmation these were truly addressing HPPD ((Halpern & Pope, 2003))

Cheifly, HPPD’s current diagnosis lacks the boundaries between the two separate diagnostic entities: flashbacks and continuous perceptual problems. This distinction is made in the literature, but this has not made its way to the DSM-V (Abraham, 1983; Abraham & Aldridge, 1993; Abraham et al., 1996; Lerner et al., 2002; Lerner et al., 2003). These reviews provide suggestions for current and alternative diagnostic groupings for HPPD. Unfortunately, neither quantitative or biological evidence has been conducted to validate the distinction between these groups. I have proposed two protocols for investigating if the clinical experience is validated.

Next, although HPPD is often characterized as a visual disorder, experience from the HPPDonline.com message board has produced some consistent themes that should be explored. Symptoms often associated with HPPD may demonstrate a pattern of consistent comorbidity, which could be assessed and investigated to seek of symptoms cross diagnostic boundaries such as presence of dissociative and derealization symptoms in the HPPD population. Next, would be listing the symptoms as validated with research, and using weighting per item develop scales of severity and disability for setting diagnostic thresholds.

As stated, the APA has no intention to abandon the categorical system, which has been in place since the DSM-III, and to receive attention the HPPD diagnosis must be proven to be inaccurate at a very basic level. Therefore, problems evident with the current categorical diagnostic criteria of Hallucinogen Persisting Perception Disorder should be considered with making improvements in the system without complete abandonment. However, this is not a difficult challenge.

[David S. Kozin]

I posted a response to the video:

I appreciate your desire to clarify diagnostic boundaries, but you assume the DSM represents the clinical reality for experience/etiology. Wrong. The text was rushed to development and included approx 12 field trials and the current DSM is criticized by clinicians for not capturing the clinical complexities of their patients. The HPPD diagnosis is not a valid representation of the disorder. I have participated and co-authored research on an advisory task force for DSM-5. I welcome discussion.