Posttraumatic Stress Disorder After a Psychedelic Experience, a Case Report

Rubin-Kahana and colleagues situate their report in the context of a recent resurgence of clinical research into classical psychedelics for psychiatric conditions, including mood disorders, substance use disorders and trauma-related disorders. They note that most contemporary studies of psychedelic compounds are conducted within structured psychedelic-assisted psychotherapy programmes, and therefore the effects of unsupervised psychedelic experiences in people with mental disorder or trauma histories remain poorly characterised. This paper presents a single clinical case intended to illustrate an adverse clinical trajectory temporally associated with an unsupervised psychedelic experience. The investigators describe a young man who, after taking LSD and DMT concurrently, recovered a previously repressed memory of childhood sexual abuse and subsequently developed posttraumatic stress disorder (PTSD) symptoms and escalating opioid use. The report is offered as a cautionary clinical vignette highlighting gaps in understanding of unsupervised psychedelic use among trauma-exposed individuals and people with substance use disorders.

This study is a retrospective clinical case report based on care provided in the Concurrent Outpatient Medical & Psychosocial Addiction Support Services (COMPASS) at CAMH, Toronto, Canada. The patient provided written consent for publication after he discontinued treatment. The treating clinicians authored the report. Clinical information was drawn from the patient's admission interview, serial clinical assessments, urine drug screens and treatment records. Diagnoses were made according to DSM-5 criteria as recorded in the clinical file. There was no experimental intervention or structured research protocol; instead the write-up recounts routine clinical management, including pharmacotherapy and psychosocial supports offered during treatment. The extracted text does not report the use of standardised research instruments beyond a mention that the patient refused to complete a PTSD scale. Key elements of the clinical management documented include initiation and titration of methadone maintenance therapy (up to 140 mg per day), a trial of sertraline (up to 75 mg per day), participation in recovery groups and occupational therapy aimed at college admission tasks. Additional recommendations (housing assistance, inpatient withdrawal admission, and antipsychotic medication when psychotic symptoms emerged) are described, along with the patient’s responses to those offers.

The patient, identified as Mr F, was 25 years old at presentation and reported onset of opioid use at age 21. He described a history of frequent recreational use of psychedelics and cannabis prior to the indexed event, and reported that after taking LSD and DMT together he recovered a memory of childhood sexual abuse that he said occurred at age 4. After this recollection he experienced persistent intrusive and distressing traumatic symptoms that he reported were numbed by opioid use. On admission his urine drug screen was positive for tetrahydrocannabinol, cocaine, heroin, morphine, methadone, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine and fentanyl. The clinical team diagnosed severe opioid use disorder and, on retrospective review of the record, concluded he met full DSM-5 criteria for PTSD at admission (the initial chart also described subthreshold PTSD with delayed expression). Mr F had no previously documented psychiatric or significant medical history and reported a childhood marked by loneliness and neglect. Both parents had histories of opioid use disorder. Treatment included methadone up to 140 mg daily and sertraline up to 75 mg daily, plus group and occupational therapy. During the first 8 months he improved, reducing opioid use to once every 2 weeks while remaining on methadone; however, after about two months of improvement he stopped sertraline, frequently missed methadone doses and relapsed to daily fentanyl and poly-substance use including cannabis, benzodiazepines, cocaine and crystal meth. Clinically, he developed preoccupations and racist remarks and later formed delusional ideas about German superiority and Nazism. Multiple clinicians assessed him and concluded he had substance-induced psychotic disorder coincident with polysubstance use. The patient refused antipsychotic treatment, would not complete a PTSD scale because he did not wish to think about the trauma, and disengaged from services after 16 months of treatment. The extracted text notes that the amounts and frequency of drug use prior to the psychedelic experience are not clearly documented, and the patient never attempted to verify the authenticity of the recovered memory.

The investigators place this case within literature on dissociative amnesia and childhood sexual abuse (CSA). They describe dissociative amnesia as an inability to retrieve autobiographical information in the absence of brain damage and note that amnesia for CSA is common; the extracted text cites clinical survey rates of amnesia between 59.3% and 64% and a general population rate of 42%. They further note that recent recollection of traumatic details is associated with especially high levels of posttraumatic symptoms, and that a history of CSA substantially increases lifetime risk of PTSD (an extracted figure states 86% of CSA survivors met PTSD criteria at some point). Rubin-Kahana and colleagues observe that LSD and DMT act principally as 5-HT2A receptor agonists and that there are prior reports suggesting classical psychedelics and DMT-containing preparations (for example ayahuasca) can facilitate recovery of memories. They also note reports that MDMA may bring up deep-seated negative emotions. The authors acknowledge a debate about the veracity of recovered memories of CSA, while pointing out that many such memories can be verified by survivors. Several limitations of the case are acknowledged. The patient never sought external verification of the recovered memory, and the later emergence of delusional beliefs raises questions about memory authenticity. The clinicians argue the delusional symptoms appeared after more than a year of care and in the context of escalating stimulant and cannabis use, so they consider it unlikely that the recovered memory was a product of psychosis. The retrospective nature of the report is highlighted as a limitation, including unclear documentation of drug amounts and frequency prior to the key psychedelic event. On implications, the authors emphasise the clinical complexity that may arise when trauma and substance use co-occur and recommend that clinicians treating people with SUD or trauma be alert to atypical presentations. They conclude that traumatised individuals, whether aware of past events or not, should use psychedelic drugs only within supervised, assisted psychotherapeutic settings, as unsupervised use may worsen clinical outcomes.