Chapter 48. Hazards of LSD psychotherapy

From the very beginning, psychiatrists were aware that LSD, like most other medicaments, poses hazards. The hazards visible during the early years were summed up in a classic 1960 paper, "Lysergic Acid Diethylamide: Side Effects and Complications," by Dr. Sidney Cohen.

Dr. Cohen sent a questionnaire to 66 researchers who were known to have administered LSD or mescaline to humans, either therapeutically or experimentally. Forty-four of them replied; they had administered LSD on more than 25,000 occasions to nearly 5,000 men and women. Dr. Cohen also searched the medical literature for published reports of adverse effects.

From the  physical point of view, LSD was found to have a remarkable record. "No instance of serious, prolonged physical side effects was found either in the literature or in the answers to the questionnaires. When major untoward reactions occurred they were almost always due to psychological factors." No physical complications were observed even when LSD was given to skid-row alcoholics with impaired liver function and generally deteriorated health.

As for adverse  psychological reactions, Dr. Cohen noted that the published LSD literature "directly records only one suicide and that in a schizophrenic patient, and a small number of short, self-limited psychotic reactions and other lesser side effects."

Dr. Cohen's survey of LSD therapists, however, turned up several kinds of adverse psychological reactions. These he divided into immediate and subsequent.

The most common, but still infrequent, immediate problem [Dr. Cohen reported] was one of unmanageability. This apparently occurs when insight into the situation is lost and the individual acts upon delusory, usually paranoids] ideas. Instances of running away from the tester, disrobing, or accidental self injury were described. . . .

Panic episodes were likewise mentioned. When these develop early they seem to represent the terror involved with the loss of ego controls. At the height of the reaction panic may be precipitated.... Finally, after many hours of frightening dissociation the subject could develop an intense fear that he will not be able to get back to his ordinary state. *

* Others have similarly commented that the  duration of the LSD trip–– more than six hours in most cases–– is a disadvantage. Few trials have as yet been made of psychotherapy with short-acting LSD-like drugs such as DMT.

Certain kinds of people, the Cohen survey revealed, are particularly likely to have bad trips of these kinds. "Those with excessive initial apprehension" are the prime example; fear of a bad trip increases the likelihood of a bad trip. Dr. Cohen also mentioned people with "rigid but brittle defensive structures, or considerable subsurface guilt and conflict."

People hostile to LSD were also noted as likely to have bad trips. "Invariably, those who take hallucinogenic agents to demonstrate that they have no value in psychiatric exploration have an unhappy time of it. In a small series of four psychoanalysts who took 100 [micrograms] of LSD, all had dysphoric [unpleasant] responses. Two Zen Buddhists were given LSD in order to compare the drug state with the transcendent state achieved through meditation. Both Zen teachers became so uncomfortable that termination [of the trip] became necessary."

The Cohen survey also noted two kinds of hazard during the day or two after LSD. "The first is a simple prolongation of the LSD state. Ordinarily, after a night's rest it is to be expected that complete cessation of the drug effect will have occurred. However, the persistence of anxiety or the visual aberrations for another day or two in wavelike undulations has been described." More frequent were short-lived depressions following LSD. These, Dr. Cohen noted, might be due to simple "letdown" on returning to humdrum everyday life, or to other factors.

While bad trips were infrequent, Dr. Cohen offered a number of suggestions for reducing the frequency still further. One was adequate screening of patients through a preliminary psychiatric interview and history-taking–– especially to exclude schizophrenics and schizoids. The briefing of the patient in advance is also "a matter of some importance, with the value of the drug interview sometimes depending on the preliminary instructions. Something of the nature of the experience and the expectations for the session are communicated at this time. Misconceptions are corrected and necessary reassurances are given ."

Precautions  during the LSD trip are also essential. "That the person under the influence of LSD should not be left alone is universally agreed. Human contact is comforting and serves as a pivot between every day reality and the strange world of LSD. Without it the patient can readily lose all orientation. Personnel in contact with the subject should be experienced and sympathetic.... The [LSD] state is a highly suggestive one with the patient responding strongly to environmental cues. He can sense the therapist's unspoken feelings with phenomenal accuracy. Impersonality, coldness and disinterest is the equivalent of being left alone."

Finally, Dr. Cohen noted that although they are rarely needed, LSD antagonists should be on hand. Several drugs are capable of terminating an LSD trip quite promptly. Psychological measures such as reassurance rather than drugs, however, are commonly used today to abort an LSD bad trip.

A much feared aftermath of LSD during the 1950s was suicide–– in part because of widespread rumors of a European suicide following LSD use, and in part because one actual LSD suicide had been reported in the medical literature. In this respect, the 1960 Cohen survey was reassuring.

The patients given LSD included many who were seriously depressed or suffering from other severe forms of mental illness. In such a population, the incidence of suicide is relatively high. Among the patients covered in the Cohen survey, the suicide rate was one per 2,500 patients. Among healthy experimental subjects given LSD, the suicide rate was zero. The rate of suicide attempts among psychiatric patients given LSD was 1 in 800; the rate among experimental subjects given LSD was zero.

During a four-year period ending in 1964, among 150 patients given from one to eighty LSD doses by Dr. E. F. W. Baker of the University of Toronto and Toronto General Hospital, one patient committed suicide a few weeks after an LSD trip and one died of "unknown causes." "This experience is not out of line with ordinary suicide risk in a comparable group of patients not subjected to this forty of treatment," Dr. Baker noted. "We know of at least nine serious suicidal attempts made by patients in this particular group before LSD therapy was instituted."

Finally, and perhaps most important, psychiatrists in 1960 were concerned that LSD might trigger not just a brief "bad trip" but a prolonged psychotic reaction lasting more than forty-eight hours. The Cohen survey confirmed that such cases do occur. They are most likely to occur, the questionnaire returns indicated, among schizophrenic or schizoid patients; hence such patients should not receive LSD. The frequency of prolonged reactions was low, however. Only one such case was reported among 1,300 experimental subjects who received LSD–– and he recovered within a few days. There were seven prolonged reactions among the psychiatric patients–– a rate of one per 550 patients. "These breakdowns happened to individuals who were already emotionally ill," Dr. Cohen commented; "some had sustained schizophrenic breaks in the past. In certain instances the unskillful management of the patient contributed to the undesirable outcome."

Dr. Cohen concluded:

This inquiry into the adverse effects of the hallucinogenic drugs indicates that with proper precautions they are safe when given to a selected healthy group. Their use in [psychiatric] patients has been associated with an occasional complication. An analysis of these incidents suggests that with the application of certain safeguards many of these side effects might have been avoided.

Drs. Jerome Levine and Arnold M. Ludwig, then psychiatrists at the United States Public Health Service Hospital in Lexington, Kentucky, commented on the Cohen survey findings that they "better support a statement that the drug is exceptionally safe rather than dangerous. [Italics in original.] Although no statistics have been compiled for the dangers of psychological therapies, we would not be surprised if the incidence of adverse reactions, such as psychotic or depressive episodes and suicide attempts, were at least as high or higher in any comparable group of psychiatric patients exposed to any active form of therapy."

Another questionnaire survey on the use of LSD in psychotherapy was undertaken in Britain in 1969 by Dr. Nicolas Malleson, psychiatrist, Fellow of the Royal College of Physicians, and member of the Advisory Committee on Drug Dependence of the United Kingdom Home Office. Dr. Malleson's survey differed from Dr. Cohen's in only a few respects. He received replies from substantially all of the therapists who had ever administered LSD to patients in the United Kingdom over a span of nearly twenty years–– 66 therapists in all. The replies covered 4,303 patients, given a total of more than 50,000 sessions (almost all of them LSD, the remainder psilocybin), plus 169 experimental subjects given a total of 448 sessions. The handful of therapists not included in the survey consisted of a few who had given LSD only to animals, plus a few who had treated only a very small number of cases. Thus for practical purposes the survey covered substantially all patients receiving LSD therapeutically in Britain down to 1969.

Two suicides were reported among the 4,303 patients:

1. "Female, late 20's, married, an atypical manic-depressive. Admitted [to mental hospital] depressed. Anti-depressant drugs and 'other therapies' having failed, LSD therapy attempted. Some symptomatic improvement. Went on leave from hospital one week after an LSD session and was found dead from barbiturate and carbon monoxide poisoning three days after."

2. Male, early 20's, psychopath, given one very small dose of LSD [25 micrograms, the minimum likely, to secure even a slight effect]. Showed no significant response. Left hospital against medical advice a few days later and hanged himself. "I think it is difficult to say," the psychiatrist reporting the case noted, "whether the patient's suicide was connected with his medication or not."

Twenty attempted suicides were reported; but "four of these were quite possibly only gestures and for seven no precise details were available." Several had made repeated suicide attempts before taking LSD.

Thirty-seven patients developed psychoses of more than forty-eight hours' duration. Of these, 9 patients recovered completely within two weeks, and 10 remained chronically psychotic; in some of these chronic cases, the reporting therapists expressed the opinion that these were potential chronic psychotics before LSD.

There were also two natural deaths during the 50,000 LSD sessions or shortly thereafter. One asthmatic patient died of acute asthma twelve hours after his third session; another dropped dead for reasons unknown during his seventh session. There was one proved coronary attack and two suspected attacks during sessions, as well as an epileptic attack–– in one patient without a prior history of epilepsy. One patient in a panic jumped out of the window, with superficial injuries; another pushed her hand through a windowpane and suffered cuts.

The bulk of the adverse reactions were among the patients receiving LSD from therapists with little LSD experience. Hospitals with the greatest experience reported relatively few adverse reactions; at Marlborough Day Hospital, for example, 6,522 LSD sessions and 50 psilocybin sessions were given to 507 patients with no suicides, no serious suicide attempts, no accidents, and only four psychotic reactions. "Treatment with LSD is not without acute adverse. reactions, but given adequate psychiatric supervision and proper conditions for its administration, the incidence of such reactions is not great," Dr. Malleson concluded. Whether a like number of equally ill patients given psychotherapy  without LSD would have had more or fewer adverse effects could not be determined.

A substantial majority of the British therapists who answered Dr. Malleson's questionnaire in 1969 were apparently of the opinion that LSD therapy is well worth the risk in cases where it is indicated. Asked whether they were still using LSD, and if not, why not, the 63 therapists who answered this question replied:

Footnotes
Chapter 48

1. Sidney Cohen, "Lysergic Acid Diethylamide: Side Effects and Complications,"  Journal of Nervous and Mental Diseases, 130 (January, 1960): 30-40.

2. Ibid., pp. 30-31.

3. Ibid., pp. 31-32.

4. Ibid., p. 32.

5. Ibid.

6. Ibid.

7. Ibid.

8. Ibid., p. 36,

9. Ibid.

10. E. F. W. Baker, "The Use of Lysergic Acid Diethylamide (LSD) in Psychotherapy,"  Canadian Medical Association Journal, 91 (December 5, 1964): 12O2.

11. Sidney Cohen, "Lysergic Acid Diethylamide," p. 39,

12. Ibid.

13. Jerome Levine and Arnold M. Ludwig, "The LSD Controversy,"  Comprehensive Psychiatry, 5 (1964): 318.

14. Nicolas Malleson, "Acute Adverse Reactions to LSD in Clinical and Experimental Use in the United Kingdom"; unpublished, provisional report, June, 1969.