Paradoxical Responses to

Chlorpromazine After LSD

CONRAD J. SCHWARZ, M.B., Ch.B.

• Chlorpromazine has heen used as one of thestandard antidotes to LSD, but there have

heen a few reports of failures in responses andof adverse reactions. Ungerleider, J. T. et .11.1reported one case which did not improve withhigh doses of oral or intramuscular chlor­promazine. Malitz, S. et a1.z noted "increasedmotor restlessness, mounting anxiety, andhrief intensification of visual hal1ucinations"fol1owing intravenous administration of chlor­promazine to terminate the LSD experiencl'in experimental suhjects. Abramson, H. A."using a suhjective questionnaire technique, re­ported that oral chlorpromazine produced "insome instances an apparently enhanced reac­tion to LSD"; this reaction was not reportedafter intramuscular injections.

The fol1owing two cases observed by theauthor would appear to support these impres­sions:

Case I.-A 33-y('ar-old voluntary pati('nt who hadhe('11 ill a mental hospital for th(· previous nine monthswith a diagnosis of ps('udOlwurotie sehizophrpnia wasadministpred 100 micrograms of LSD-2!5 intravenous­ly and was obsPTv('d over the n('xt four hours. Heexhibited marked fluctuations in mood ranging fromsilly euphoria to ('xtreme amidy with subjective feel­ings of panic. The intervit'w was tPTminated by givinghim 25 mgm of chlorpromazine intravenously. Thisimmt'diatcly produced t'xtreme anxiety and he shouted"\Vhere am I? Take m(' out of this. Don't ever makeme go through this again." He thought he had beengiven another injection of LSD "to put me back intoit and make me talk." Ill' settled and slept overnight,but about half an hom after being given a 25 mgmtablet of chlorpromazine next morning, he experi­enced another episode of anxiety and accused thenmse of having given him "another dose of that stuff."He had similar reactions to oral chlorpromazine whentwo other 25 mb'Tll tablets were given to him that day,but did not report any side-e/ft'cts to the drug on thesccond and third days after tl1(' LSD expprience.

Dr. Schwarz is Consultant Psychiatrist, StudentHealth Service, University of British Columbia, Van­couver, B. C., Canada.

210

ClIse 1I.-A 22-year-old university studt'nt T{'portedto the Health Services three weeks after his thirdLSD "trip." The first two had been uncomplicated,but on the third one he had experienced panic, feltterrified, and had visual hallucinations of "people'sguts all over the place . . . black hands coming outof nowhere." Over the next three weeks he had hadseveral spontaneous recurrences of anxiety and visualhallucinations. He was given a prescription for chlor­promazine 25 mgm t.Ld. \Vhen seen again two weeksIatpr he repoTtpd that the recurrencps sPt'med to beless frequent over the past week, but indicatpd thathe had felt little improvement dming the first wet'k.When asked about the medication he stated he hadstopp('d taking it after the first two days, because itseempd to make him feel worse. He stated "In fact,I know it sounds funny, but I got quite paranoidafter the first pill and wondered what kind of a gameyou were playing with me." He likened his subjec­ti\'(' state after taking the chlorpromazine to theparlier spontaneous recurrences, and specifically re­ealled rp-experiencing the "black hands" hallucination.

Any explanations of the above phenomenado not yet seem possible, and they appearopen to psychological and biochemical the­ories. A psychological theory would have torest somewhat on coincidence and would haveto explain how the first patient reacted in asimilar manner to intravenous and oral formsof the same drug when he did not appear tohave any direct knowledge of their similarity.If a biochemical theory were entertained itwould have to be rather complex and explainwhy such reports are so rare when chlor­promazine is so Widely used as an antagonistof LSD. It may be that certain individualsare somehow susceptible to chlorpromazinewhich produces a non-specific mild akathisiawith associated anxiety on which is super­imposed the psychological component derivedfrom the recent LSD experience. Such a re­sponse to chlorpromazine might also be ex­plained on the basis that the dose was too lowto counteract the LSD state or the symptomsof the recurrences.

On the other hand, the frequency withwhich spontaneous recurrences are reporteddoes lead to the suspicion that LSD or some

Volume VIII

PARADOXICAL RESPONSES-SCHWARZ

metabolite is still present in the brain for sometime after the ingestion of LSD. Such recur­rences often seem to be preceded by a mildstate of anxiety, and it may be that someneurohormonal mechanism is called into playwhich interacts with an LSD residue. Thatapparently similar phenomena can occur inassociation with the administration of anotherchemical compound, i.e. chlorpromazine, lendsfurther support to the possibility of a bio­chemical mechanism being involved.

It should also be borne in mind that knowl­edge about the tranquilizing value of pheno­thiazines is widely circulated in the lay psy­chedelic literature and it may be that some ofthe so-called "spontaneous" recurrences in

people who take LSD informally may, ondirect enquiry, tum out to be associated withthe ingestion of chlorpromazine.

REFERENCES

1. Ungerleider, J. T., Fisher, D. D., and Fuller, M.:The Dangers of LSD, lAMA, 197:389, 1966.

2. MaUtz, S., Wilkins, B., and Escover, H., in West,L. J.: Hallucinations, Grune and Stratton. N.Y.,1962.

3. Abramson, H. A.: Lysergic Acid DiethylamideAntagonists: Chlorpromazine, J. Neuropsychiat.,1:307, 1960.

University of British ColumbiaVancouver, British Columbia, Canada

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There is some ('vidence that psychotherapists who dedicate themselves to special schoolspossess needs which the theoretical doctrines of the schools appear to satisfy, or cherishpt'rsonality traits which coordinate with the school's methodological trajectories. Undersuch circumstances, the postulates of a school will provide the therapist with an anchor tostahilize him in the unchartered sea of treatment. His abiding faith in his system willI'nable him to approach with assurance the problems of his patient. It will give him confi­dent'e in the patient's capacities to benefit from treatment. At the same time the school'sleclmical maneuvers, appealing to his logic, permit him to operate spontaneously and"genuinely" to heighten the patient's expectations of cure. These maneuvers are designedto deal with the presenting problem in terms of the assumptions and credos treasured by theparticular school. ... The fact that in the hands of skilled practitioners, patients get wellthrongh the use of any of the approaches ...would seem to indicate that the psychothera­pt'utic experience ent'Ompassf'S factors other than those assigned to it by the differenttheoretical schools ...

-LEWIS R. WOLBERG, M.D., The Technique of Psychotheral1Y,Grune and Stratton, New York, 1967.

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