Psychedelic use disorders

[mistafab]

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Seen a handful of curious cases of psychedelic use disorders. Seems to have an interesting pattern in how it changes/hijacks peoples thinking when compared to other substances of abuse. I'll give 2 short case vignettes.

Young woman with longstanding overcontrol pattern at a high power job starts experimenting with psilocybin mushrooms. Never had other use history. Use starts expanding to daily 'microdosing' which became non micro quickly. Over the course of the next few years, loses everything. Lost high power job. Use pattern expands to other substances (Ayahuasca, Ibogaine, peyote, etc.). Many 'retreats' per year. Spiritual journeys become the most important thing in life. Starts to develop overwhelming belief that spiritually she is getting 'closer' and that boundaries between others have dissolved. By the time she sees me, she is living out of a car - no money, and all relationships besides psychedelic users is gone. No "friendships" - everyone is just a 'guide' or a 'shaman' by this point. Feels she is doing something very meaningful.

Big shot C-Suite at company gets into psilocybin. Use starts expanding yada yada, doing many, many 'retreats.' Boundaries get blurred. Doing many different psychedelics, also MDMA (which is somewhere between stimulant and psychedelic). Inappropriate sexual talk often, starts having inappropriate sexual relationships. Use is 'spiritual' and 'meaningful.' Sex and spirituality become overvalued. Planning next retreat with their marriage in the dumps due to complete disconnect from reality - the Big Shot thinking he's uncovering all these 'truths' meanwhile he's just a self-absorbed jerkoff to everyone in his life and somehow spiritually superior. He is on the outs with his job.

There seems to be an interesting pattern specific to psychedelic use compared to other use disorders. Both of these cases I gave the "severe" psychedelic use disorder to. They both get this sense that their use is "important" and "meaningful" and do not consider it problematic. Very unique compared to other substances in their form of denial gathers this 'spiritual' edge that makes them superior to other humans. Interesting how people using psychadelics tend to think they are becoming more unique and connected, yet it seems they start to all look the same - perhaps these drugs alter areas of the brain in similar ways for most people. Not sure if there is a 'spiritual' center of the brain, but given that psychedelic abuse tends to create similar-thinking people - I'm assuming there must be one.

Anyone else run into psychedelic use disorder recently?

 

[oliversacks4thewin]

Fascinating cases to hear about your first-hand experience.

Your stories had me go back to a recent lecture I attended on the use of psychedelic-assisted psychotherapy and found the following:

"The same brain structures associated with hyper-religiosity in psychotic patients, such as the right temporal lobe and right prefrontal cortex, are also altered during the acute effects of hallucinogens. Neuroimaging and functional studies consistently show that classic serotonergic hallucinogens (e.g., psilocybin, LSD) induce marked changes in activity and connectivity in the prefrontal cortex (including the right prefrontal cortex), anterior cingulate cortex, and temporal lobes, particularly the medial and lateral temporal cortices. These regions are rich in 5-HT2A receptors, the primary target of these substances, and are implicated in the modulation of perception, self-referential processing, and the emergence of mystical or religious experiences.

Both psychotic and psychedelic states share alterations in thalamo-cortical and cortico-striato-thalamo-cortical circuits, with hallucinogens producing hyperfrontality (increased prefrontal and temporal activity) and disrupted connectivity in networks involving the prefrontal cortex, temporal cortex, and limbic structures."

It stands to reason, given the implicit structures, that the adaptive function would be to focus on these "experiences" to the detriment of all other forms of function. Hope it helps with the conceptualization and treatment.

 

[FatherPsychiatry]

Don't know about "use disorder" per se, but I remember two patients in my treatment setting (jail) in the past year that I was convinced only used psychedelics, whereas everyone else here is pan + meth, fent, Cannabis, ETOH, etc etc.

To me, both were previously higher functioning individuals with not-horrible backgrounds, well at least compared to the background of a typical jail inmate (very low socioeconomic status, hx of child abuse etc). Both white guys, also not the most common group in the jail. Both, (to me) clear narcissists for whom the psychedelic use was just the newest cherry on top of their general 'self-absorbed jerkoff to everyone in his life and somehow spiritually superior' aura like your second example. That was my sense - they got bored of their fancy C-Suite type job, or maybe they sucked at it, got kicked out, but due to their personality traits, lacked insight into why. And they end up in some objectively bad position, but again their narcissism robs them of the ability to really appreciate the position they're in. Both told me they would continue using psychedelics when they're released.

 

[Stagg737]

Psychedelics today are just the cocaine of the 80’s and 90’s. Drug of choice for all the nepo trust fund babies who think they’re hot s*** and want to party spiritually awaken.

 

[Stagg737]

Seriously though, I wonder if some of the symptoms described here are actually caused by the psychedelics or if they’re just disinhibiting or unmasking underlying personality traits. Mistafab’s first woman seems like a personality change, but the other examples sound like there’s some significant underlying cluster B traits and I wonder if she also had traits that she hid or were just less prevalent/obvious due to her previous motivation for achievement. If so, that sounds like less of a personality change and more of a shift in motivation as she still seems driven to achieve enlightenment.

I’ll add that I’ve also seen several patients where the same thing happens when they suddenly started or become heavy cannabis users without other psychedelic use. Ie, cannabis intoxication as a spiritual experience that has “opened their minds” to experiences that non-users can’t comprehend unless they start smoking it themselves. Some of the narcissistic traits described here resonate with the beliefs and attitudes of those hardcore potheads who go beyond advocation to proselytization of cannabis use.

 

[Candidate2017]

Don't know about "use disorder" per se, but I remember two patients in my treatment setting (jail) in the past year that I was convinced only used psychedelics, whereas everyone else here is pan + meth, fent, Cannabis, ETOH, etc etc.

To me, both were previously higher functioning individuals with not-horrible backgrounds, well at least compared to the background of a typical jail inmate (very low socioeconomic status, hx of child abuse etc). Both white guys, also not the most common group in the jail. Both, (to me) clear narcissists for whom the psychedelic use was just the newest cherry on top of their general 'self-absorbed jerkoff to everyone in his life and somehow spiritually superior' aura like your second example. That was my sense - they got bored of their fancy C-Suite type job, or maybe they sucked at it, got kicked out, but due to their personality traits, lacked insight into why. And they end up in some objectively bad position, but again their narcissism robs them of the ability to really appreciate the position they're in. Both told me they would continue using psychedelics when they're released.

Yes. People riding the magic psychedelic van fall into one of two camps: super-polys (low socioeconomic, subs use began in early/mid-teens, psychedelics are just one the many subs they use, but they aren't really hooked on them because... opioids and/or meth), and the narcissists (higher socioeconomic, "I'm not a drug user, I'm on a spiritual journey, F off because all you are just sleepwalking").

 

[TexasPhysician]

I’m the medical director at an addiction facility with a typical volume of about 200 and utilize ketamine/spravato outpatient. Psychedelics causing such dysfunction as the only or primary drug of choice is quite rare and typically a function of personality disorders.

The retreats I typically see attract high achievers because it is a luxury experience. Most can’t afford thousands for luxury accommodations, catered food, on-site counselors, etc.

 

[Taddy Mason]

I’m the medical director at an addiction facility with a typical volume of about 200 and utilize ketamine/spravato outpatient. Psychedelics causing such dysfunction as the only or primary drug of choice is quite rare and typically a function of personality disorders.

The retreats I typically see attract high achievers because it is a luxury experience. Most can’t afford thousands for luxury accommodations, catered food, on-site counselors, etc.

Yeah, I’m addiction psych, did both residency and fellowship and currently work in a major metro area, and don’t think I’ve ever encountered a true psychedelic use disorder. The people I’ve encountered where psychedelics are their substance of choice don’t meet criteria for a use disorder but definitely seem to have certain personality traits. The closest I’ve come to giving that diagnosis was with an adolescent patient who I was seeing for OUD during fellowship who developed 5-HT syndrome from “LSD” (I have reason to strongly suspect he had actually taken a NBOMe and not LSD). That incident was actually scary enough for him to start engaging in treatment and start MOUD as well as go to a residential treatment program all on his own accord.

 

[Celexa]

What does their sleep look like? These could easily be descriptions of mania +/- personality factors. Not questioning that the substance played a large role in their downward spiral, but there are some interesting technical debates worth having about the role of the substance itself and whether someone pursues the direct effect a substance has on their brain vs some other aspect of social behavior and experience linked to the settings where a substance is used.

My practice is not addiction focused but I do see a decent amount, like others in this thread I've never encountered someone i would say had a pure psychedelic use disorder. Have definitely met people who had bad trips/awful and lingering side effects from their use, though. And at least one classic "i thought i could fly oops gravity still exists" ortho trauma consult....