This case report (n=1) describes a woman with generalized anxiety disorder who experienced extreme anxiety, panic, and hopelessness during and up to three days after taking ayahuasca. This is the first description of a prolonged ‘bad’ trip in the literature.
Abstract
“Background and aims Ayahuasca is a dimethyltryptamine- and β-carboline-rich hallucinogenic beverage traditionally used by indigenous groups of Northwest Amazonian for ritual and therapeutic purposes. Animal and human studies suggest that ayahuasca has antidepressant and anxiolytic potentials and has a good safety profile. However, anxiety-like reactions may also occur after ayahuasca intake, although they are rare.
Methods Case report.
Results Here, we describe a case of a non-medicated, symptom-free young female with generalized anxiety disorder, who experienced intense anxiety, panic, and hopelessness during and for 3 days after participating in an ayahuasca ritual. The symptoms appeared in the first hours after ayahuasca intake and were gradually reducing in the following hours/days, but were intense enough to cause significant suffering to her, who needed to seek psychiatric help and restarted pharmacological treatment.
Conclusions Although “bad/horror trips” with anxiety features may occur during the acute effects of ayahuasca and other hallucinogens, to the best of our knowledge, this is the first report of a subacute/prolonged anxiety-like reaction to this substance. Ayahuasca should be used with caution in people with a history of anxiety disorders.”
Authors: Rafael G. dos Santos, Flávia L. Osório, José Alexandre S. Crippa & Jaime E. C. Hallak
Summary
INTRODUCTION
Ayahuasca is a botanical hallucinogen traditionally used by indigenous groups throughout the Northwestern Amazon for ritual and therapeutic purposes. It is prepared by prolonged decoction of the stems of the Banisteriopsis caapi vine combined with the leaves of the Psychotria viridis bush.
Ayahuasca administration to healthy volunteers in controlled settings is well tolerated. Nausea and vomiting are the most frequent adverse effects reported, and usually disappear completely after the expected time of action of ayahuasca without the need of medical intervention.
Adverse reactions to hallucinogens can range from acute, short-lived reactions involving anxiety, fear, panic, or psychotic symptoms to subacute and chronic maladaptive/dysfunctional reactions with anxiety or psychotic features. However, hallucinogen-related disorders are generally thought to have low incidence, low persistence, and high rates of recovery.
Long-term ayahuasca use is not associated with increased psychopathology, cognitive deficits, or personality disorders, and ayahuasca may even improve mental health. Moreover, studies in animals and humans suggest that ayahuasca has anxiolytic, antidepressive, and antiaddictive properties.
Ayahuasca may cause anxiety-related adverse reactions in some people. Here we report the case of a young adult female with generalized anxiety disorder who experienced prolonged anxiety-like symptoms.
CASE PRESENTATION
Ms. A, a 25-year-old Brazilian female, was diagnosed with GAD and chronic insomnia when she was 20 years old. She contacted us by e-mail after reading publications on ayahuasca and anxiety by our group, and all contact with her was made by e-mail.
Ms. A had consumed hallucinogens and MDMA on a few occasions, and had been a daily cannabis smoker for the preceding 8 years. She was not using hallucinogens/MDMA at the time of the episode, and did not consume cannabis 2 days prior to or during the episode.
After using MDMA in Europe, Ms. A was diagnosed with GAD and treated with paroxetine, zolpidem, and alprazolam for 8 months, but her insomnia did not improve. After experiencing a sudden, unexpected, and spontaneous “spiritual awakening”, she decided to stop taking her medications without medical advice.
Ms. A did not provide a detailed description of the ritual setting, or if there was any preparation before the ritual or integration after the ritual. Ms. A ingested two consecutive ayahuasca doses, separated by a 2-hr interval, and experienced intense anxiety, panic, and hopelessness, as well as arrhythmia. She did not report the presence or emergence of complicated and anxiety-provoking psychological material during the episode.
The organizers tried to make Ms. A calm and comfortable, but her anxiety symptoms persisted for the next 8 hours. She resumed her psychiatric treatment when she finally felt better, and is now using mirtazapine, clonazepam, and zolpidem everyday.
DISCUSSION
Ayahuasca use in ritual settings is rarely associated with prolonged dysphoric/anxiogenic reactions, which is in line with studies with other hallucinogens suggesting a low incidence of prolonged dysphoric/anxiogenic reactions both in controlled contexts and in population studies.
In controlled settings involving the administration of ayahuasca and other hallucinogens, uncommon but small increases in anxiety may occur, but only after high doses and in a minority of volunteers.
Regarding subacute/prolonged adverse reactions, there are no descriptions of such an event associated with controlled administration of ayahuasca. However, 7 of 110 subjects reported negative psychological effects following days/weeks of psilocybin administration, including concentration problems, mood swings, reactivation of old problems, memory problems, and being pensive and introverted.
Regarding the low incidence of psychopathological adverse reactions in the context of regular ayahuasca use, prospective studies following novice ayahuasca users are necessary to improve our understanding of ayahuasca and psychopathological effects.
The mechanisms involved in the anxiogenic effects described in this case are not well understood. However, it is likely that DMT and its agonist activity at cortical 5-HT2A receptors are responsible for these effects.
Ms. A’s prolonged negative reaction to ayahuasca might have been modulated at least in part by the history of a panic disorder diagnosis in her family and her previous GAD diagnosis, and the uncompleted treatment of her anxiety disorder with selective inhibitors of serotonin reuptake may have predisposed her to an anxiety-like reaction.
Ms. A’s negative reaction to ayahuasca might have been influenced or exacerbated by a poor preparation, guiding, and integration of her experience, but she did not provide details about any of these factors and did not report that they were especially relevant in her experience.
Ms. A experienced a severe ayahuasca “bad trip” that required her to restart her pharmacological treatment. Her arrhythmia was a significant contributory factor behind her reoccurring anxiety symptoms.
Ayahuasca use should be made with caution in people with a history of anxiety disorders, given the potential high morbidity associated with prolonged drug-induced anxiety disorders.
The volunteer for allowing us to publish her case provided financial support for this research. All authors had full access to all the data and had final responsibility for the decision to submit for publication.