Focusing on the negative: cases of long-term negative psychological responses to psychedelics

Abstract

Background: Recent controversies have arisen regarding claims of uncritical positive regard and hype surrounding psychedelic drugs and their therapeutic potential. Criticisms have included that study designs and reporting styles bias positive over negative outcomes.Aim: The present study was motivated by a desire to address this alleged bias by intentionally focusing exclusively on negative outcomes, defined as self-perceived ‘negative’ psychological responses lasting for at least 72 hours after psychedelic use. A strong justification for this selective focus was that it might improve our ability to capture otherwise missed cases of negative response, enabling us to validate their existence and better examine their nature, as well as possible causes, which could inspire risk-mitigation strategies. Methods: Via advertisements posted on social media, individuals were recruited who reported experiencing negative psychological responses to psychedelics (defined as classic psychedelics plus MDMA) lasting for greater than 72 hrs since using. Volunteers were directed to an online questionnaire. These data were analysed using quantitative methods. A key second phase of this study involved reviewing all of the submitted cases, identifying the most severe – e.g., where new psychiatric diagnoses were made or pre-existing symptoms made worse post psychedelic-use – and inviting these individuals to participate in a semi-structured interview with two members of our research team, where relevant experiences and backgrounds were examined in greater depth. Based on the content of these interviews, a brief summary of each case was compiled, and an explorative thematic analysis was used to identify salient and consistent themes and infer common causes. Results: Thirty-two individuals fully completed an onboarding questionnaire (56% male, 53% < age 25). 37.5% of completers had a psychiatric diagnosis that emerged after their psychedelic experience, and anxiety symptoms arose or worsened in 87%. Twenty of the seemingly severer cases were invited to be interviewed; of these, 15 accepted an in-depth interview that lasted on average 60 minutes. This sample was 40% male, mean age = 31±7. Five of the fifteen (i.e., 33%) reported receiving new psychiatric diagnoses after psychedelic-use and all fifteen reported the occurrence or worsening of psychiatric symptoms post use, with a predominance of anxiety symptoms (93%). Distilling the content of the interviews suggested the following potential causal factors: unsafe or complex environments during or surrounding the experience, unpleasant acute experiences (classic psychedelics), prior psychological vulnerabilities, high- or unknown drug quantities and young age.Conclusion: The current exploratory findings corroborate the reality of mental health iatrogenesis via psychedelic-use but due to design limitations and sample size, cannot be used to infer on its prevalence. Based on interview reports, we can infer a common, albeit multifaceted, causal mechanism, namely the combining of a potent pro-plasticity drug (often ‘over-dosed’) with adverse contextual conditions and/or special psychological vulnerability - either by young age or significant psychiatric history. Results should be interpreted with caution due to the small sample size and selective nature of the recruitment approach.

Extended difficulties following the use of psychedelic drugs: A mixed methods study

“…In Simonsson’s 2023 study, 78.6% of participants reported they were glad they had used psychedelics, after reflecting on their most difficult experiences [ 16 ]. A third of the participants interviewed by Bremler et al attributed personal growth to the difficulties triggered by their psychedelic experience [ 27 ]. Gashi et al also previously showed that ‘bad trips’ can be narratively transformed into valuable experiences [ 51 ].…”

“…Bremler et al interviewed individuals experiencing long-term negative effects from psychedelic use and found that 80% reported experiencing a sense of similarity or connection to an unpleasant psychedelic experience [ 27 ]. Some referred to this re-experiencing as ‘flashbacks’ or ‘emotional flashbacks’ and some reported re-experiencing physical symptoms such as nausea they had experienced during the original psychedelic trip.…”

“…Some referred to this re-experiencing as ‘flashbacks’ or ‘emotional flashbacks’ and some reported re-experiencing physical symptoms such as nausea they had experienced during the original psychedelic trip. Almost half of the interviewed participants (46.7%) described feelings of disconnection and isolation [ 27 ]. The same number of participants described derealization experiences, including feeling out-of-body and an altered sense of reality around them, sometimes described as ‘losing connection with reality’.…”

“…Most subjects, but not all, had a personal or family history of psychosis or mania. In Bremler et al’s study 13–16% presented with overtly psychotic symptoms following their experience (e.g., highly unusual / magical ideas or auditory hallucinations) [ 27 ].…”

“…The previously mentioned study by Carbonaro et al suggests that the duration of the challenge is crucial in determining whether the experience is beneficial or harmful; the latter may be more likely with longer duration of difficult experiences [ 15 ]. Bremler and colleagues, based on their interview reports, highlight adverse contextual conditions and/or special psychological vulnerability (young age or psychiatric history) [ 27 ]. When feelings of increased sensitivity and vulnerability persist, they may lead to prolonged states of fear and anxiety.…”