Psychedelic-Related Psychosis: From Model Psychosis to Psychotherapy

Psychotic symptoms are uncommon and non-specific adverse effects of classic (serotonergic) psychedelics such as lysergic acid diethylamide (LSD), psilocybin, and mescaline. They can emerge during the acute phase of psychedelic drug effects, persist into the subacute ("afterglow") period, or, in rare cases, develop into long-term psychotic illness. Across all three scenarios, the symptoms can be deeply distressing due to their rapid changes, unpredictability, and significant adverse behavioral consequences.Psychedelics have a long history of use as research models for schizophrenia because of the phenomenological overlaps between their acute effects and the core symptoms of psychosis. This "model psychosis" paradigm, however, has been widely criticized: although certain acute symptoms may appear similar, the etiology and psychodynamic background of primary psychosis only partially apply to psychedelic-related psychosis. Moreover, it remains unclear whether psychotic symptoms following the use of classic psychedelics differ meaningfully from those associated with other substances, such as dopaminergic stimulants or cannabis.A transient porosity of ego boundaries is a core feature of acute psychedelic states, ranging from heightened feelings of connectedness with oneself and others to complete ego dissolution. These experiences are often perceived as positive and may be followed by a subacute phase characterized by sustained increases in openness to new experiences. In some cases, however, ego dissolution may become fear-inducing and progress from challenging but manageable experiences to paranoid psychotic reactions that require therapeutic guidance and intervention.In this chapter, we examine phenomenological similarities and differences between psychedelic-induced psychosis and primary psychosis. Consistent with current international diagnostic classification systems, we conclude that, with increasing temporal distance from the initial psychedelic "index" experience that predated the symptoms, persisting psychedelic-induced psychotic symptoms become indistinguishable from primary psychosis. Finally, we present a psychodynamic therapeutic approach for schizophrenia-spectrum psychosis that may, to some extent, be adapted to psychotic symptoms observed across all three phases of psychedelic drug effects.